Amber Creek Memory Care Community

Based on documentation review and interview, the manager failed to ensure disaster drills for employees were conducted on each shift at least once every three months. The deficient practice posed a risk if employees were unable to implement the disaster plan. Findings include: 1. In review of facility documentation, revealed a caregiver schedule. The schedule revealed a day shift, evening shift, and night shift. 2. In an interview, E1 reported the day shift started at 6:00 AM and ended at 2:00 PM, evening shift started at 2:00 PM and ended at 10:00 PM, and the night shift started at 10:00 PM and ended at 6:00 AM. 3. A review of facility documentation revealed the following: - Disaster drills for the day shift dated May 7, 2024, and September 27, 2024; - Disaster drills for the evening shift dated January 4, 2024, and May 6, 2024; and - Disaster drills for the night shift dated December 7, 2024, April 5, 2024, and July 24, 2024. The review revealed more than three months between the aforementioned drills. 4. In an interview, E1 acknowledged disaster drills were not conducted with employees, on each shift, at least once every three months. This is a repeat citation from the compliance inspection conducted on April 12, 2023.

Based on documentation review, record review, and interview, the healthcare institution failed to implement tuberculosis (TB) infection control activities as specified in R9-10-113, for two of three sampled residents and one of four sampled staff. The deficient practice posed a TB exposure risk to residents and staff. Findings include: 1. R9-10-113(A), states: "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B) (1)." 2. A review of R1's and R3's medical records revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if R1 and R3 had signs or symptoms of TB. Based on R1's and R3's acceptance dates, this documentation was required. 3. In an interview regarding risk assessments and signs or symptoms screening, E1 stated, "I didn't know that was for residents as well." E1 reported risk assessments and signs or symptoms screenings were not done for residents. 4. A review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used." 5. A review of E1's personnel record revealed E1 worked as the Executive Director and had a hire date of June 13, 2023. The review revealed a document titled "Integrated Tuberculosis (TB) Screening and Risk Assessment Form for Newly Hired HCP." However, the "Integrated Tuberculosis (TB) Screening and Risk Assessment Form for Newly Hired HCP" was not completed until June 25, 2024. The review revealed a document titled "PPD (TB) SKIN TEST SCREENING." The document revealed the first TST was read on June 16, 2023, and the second TST was read on July 13, 2023. 6. In an interview, E1 reported the "Integrated Tuberculosis (TB) Screening and Risk Assessment Form for Newly Hired HCP" was the first risk assessment and signs or symptoms screening completed for E1. 7. In an interview, E1 reported the facility was not conducting risk assessments and signs or symptoms screenings until E1 started as the Execu

Based on documentation review, interview, and record review the governing authority failed to administer a training program for all staff regarding fall prevention and fall recovery, including initial training and continued competency training. The deficient practice posed a risk if a staff member was not properly trained to assist a resident who had fallen and was unable to recover independently. Findings include: 1. A review of Department documentation revealed a Plan of Correction dated April 30, 2023. The Plan of Correction stated: "Fall Prevention training was scheduled prior to Survey visit and conducted the day after the survey visit, with nineteen employees in attendance. Fall Prevention and Recovery training will be provided as part of new hire training and annually for all staff." 2. In an interview, E10 reported the facility had a new fall prevention and recovery training policy and procedure. E10 reported the policy and procedure indicated fall prevention and recovery training would be conducted at orientation and annually thereafter for all staff. 3. A review of E1's personnel record revealed E1 worked as the Executive Director and had a hire date of June 13, 2023. However, the review revealed E1 did not have fall prevention and fall recovery training until January 24, 2024. 4. In an interview, E1 reported fall prevention and fall recovery was conducted once a year. E1 reported the training was conducted on April 13, 2023, and January 24, 2024. E1 confirmed the training dated January 24, 2024, was E1's first fall prevention and fall recovery training at this facility. 5. A review of E7's personnel record revealed E7 worked as a caregiver and had a hire date of September 28, 2019. However, the review revealed E7 did not complete the aforementioned training until January 24, 2024. 6. A review of E8's and E9's personnel records revealed the following: - E8 worked as a caregiver and had a hire date of August 6, 2022; - E9 worked as a caregiver and had a hire date of March 8 2017; and - No documentation demonstrating E8 and E9 completed fall prevention and fall recovery training. 7. In an interview, E1 reported E8 and E9 were not present at the April 23, 2023, or January 24, 2024, trainings. This is a repeat citation from the compliance inspection conducted on April 13, 2023 and April 7, 2022.