Beehive Homes of Page, Elk Rd

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of evidence of freedom from infectious tuberculosis (TB), as specified in R9-10-113, for three of four personnel sampled. The deficient practice posed a potential TB exposure risk to residents. 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 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." 3. A review of facility documentation revealed a staff schedule for November 2025. The schedule revealed E4 had been scheduled to work throughout November. 4. A review of E4's personnel record revealed a TB skin test from November 2024 along with a signs and symptoms screening. However, a second TB skin test was not available for review. 5. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis before or within seven calendar days after the resident's date of occupancy, and as specified in R9-10-113, for two of two residents sampled. Findings include: 1. A review of R1's medical record revealed documentation of negative TB skin test from May 2023. However, documentation of a TB screening questionnaire was not available for review at the time of inspection. 2. A review of R2's medical record revealed documentation of negative TB skin test from March 2021. However, documentation of a TB screening questionnaire was not available for review at the time of inspection. 3 . In an exit interview, the findings were discussed with E1 and no additional information was added.

Based on record review and interview, the manager failed to ensure the resident submitted documentation dated within 90 days prior to admission, signed by a registered nurse or medical practitioner, stating whether the resident would require continuous medical services, continuous or intermittent nursing services, or restraints for two of two sampled residents,. Findings include: 1. A review of R1's medical record revealed documentation, dated within 90 days prior to admission, signed by a registered nurse or medical practitioner, stating whether the resident would require continuous medical services, continuous or intermittent nursing services, or restraints, was not available for review. 2. A review of R2's medical record revealed documentation, dated within 90 days prior to admission, signed by a registered nurse or medical practitioner, stating whether the resident would require continuous medical services, continuous or intermittent nursing services, or restraints, was not available for review. 3. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on record review and interview, the manager did not ensure a resident's medical record contained documentation of the resident's orientation to exits from the assisted living facility, for two of two residents sampled. The deficient practice posed a risk if a resident was unaware of the evacuation path to be used in an emergency. Findings include: 1. A review of R1's medical records revealed documentation of R1's orientation to exits from the assisted living facility was not available for review. 2. A review of R2's medical records revealed documentation of R2's orientation to exits from the assisted living facility was not available for review. 3. In an exit interview, E1 reported the orientation was completed at admission. E1 acknowledged R1's and R2's medical record did not contain documentation of the R1's and R2's orientation to exits from the assisted living facility.

Based on documentation review and interview the manager failed to ensure that policies and procedures were reviewed at least once every three years. Findings include: 1. Review of the facility policy and procedure manual revealed documentation indicating that the manual had been created in 2015. However, there was no documentation reflecting that the manager had reviewed the policies and procedures. No additional documentation indicating that the policies and procedures had been reviewed at least once every three years was available for review. 2. During an interview, E1 acknowledged that the required documentation was not available for review.

Based on documentation review and interview, the manager failed to ensure that a quality management plan is established, documented and implemented that includes the frequency of submitting a documented report to the governing authority. Findings include: 1. The facility quality management plan did not include the frequency of submitting a documented report to the governing authority. 2. During an interview, E1 acknowledged the required documentation was not included in the facility quality management plan. This is a repeat deficiency from the compliance inspection conducted on September 29, 2022.

Based on record review, observation and interview, the manager failed to ensure that one of one sample service plans for a resident who was storing medication in their bedroom, included how the medication would be stored and controlled. Findings include: 1. During an interview, E1 indicated that R2 self-administered some of their own medications and stored the medications in their room. 2. The record for R2 contained a service plan dated August 21, 2023 that did not include how the resident's medication would be stored and controlled. 3. During an interview, E1, acknowledged the service plan did not indicate how the resident's medication would be stored and controlled in their room.

Based on record review and interview the manager failed to ensure that two of three sample resident records contained service plans that when updated, were signed and dated by the resident or resident's representative. Findings include: 1. The record for R1, contained a service plans dated April 4, 2023 and October 4, 2023 that did not contain the dated signature of the resident or the resident's representative. 2. The record for R3, contained a service plan dated March 21, 2023 that did not contain the dated signature of the resident or the resident's representative. 3. During an interview, E1 acknowledged that the service plans did not reflect the required dated signatures. This is a repeat deficiency from the compliance inspections conducted on November 3, 2021 and September 29, 2022.

Based on record review and interview the manager failed to ensure that two of three sample resident records contained documentation of a written service plan that when updated, was signed and dated by the manager or the manager's designee. Findings include: 1. The record for R1, personal care, contained service plans dated April 4, 2023 and October 4, 2023 that did not contain the dated signature of the manager or the manager's designee. 2. The record for R3, personal care, contained a service plan dated March 21, 2023 that did not contain the dated signature of the manager or the manager's designee. 3. During an interview, E1 acknowledged that the resident's service plans did not reflect the required dated signatures.

Based on record review and interview, the manager failed to ensure that two of three sample resident records contained documentation of service plans that when updated, were signed and dated by the nurse or medical practitioner who reviewed the service plans. Findings include: 1. The record for R1 (personal care, receiving medication administration services), contained service plans dated April 4, 2023 and October 4, 2023 that did not reflect the dated signature of the nurse or medical professional who reviewed the plans. 2. The record for R3 (personal care, receiving medication administration services), contained service plans dated March 21, 2023 and September 21, 2023 that did not reflect the dated signature of the nurse or medical professional who reviewed the plan. 3. During an interview, E1 acknowledged that the service plans did not reflect the dated signature of the nurse or medical professional. This is a repeat deficiency from the compliance inspections conducted on November 3, 2021 and September 29, 2022.

Based on documentation review and interview the manager failed to ensure that policies and procedures for medication administration were reviewed and approved by a medical practitioner, registered nurse, or pharmacist. Findings include: 1. Review of the facility policy and procedure manual revealed documentation indicating that the manual had been created in 2015. However, there was no documentation reflecting that the medication administration policies and procedures had been reviewed and approved by a medical practitioner, registered nurse, or pharmacist. No additional documentation indicating that the policies and procedures had been reviewed was available for review. 2. During an interview, E1 acknowledged that the required documentation was not available for review.

Based on observation and interview, the manager failed to ensure that a current toxicology reference guide was available for use by personnel members. Findings include: 1. The toxicology guide available for use by personnel members was the Toxicology Handbook, 3rd. edition. 2. The Internet web site for the toxicology guide revealed that a more current edition was available for distribution. 3. During an interview, E1 acknowledged that a current toxicology reference guide was not available for use by personnel members.

Based on observation and interview, the manager failed to ensure that oxygen cylinders were secured. Findings include: 1. One large and one small oxygen cylinders were observed sitting upright and unsecured on R2's bedroom floor. 2. During an interview, E1 acknowledged the oxygen cylinders were not secured.