Chaparral Winds Assisted Living

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee or volunteer included documentation of evidence of freedom from infectious tuberculosis (TB), if required for the individual according to subsection (A)(8), for one of four sampled personnel members. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1.Arizona Administrative Code (A.A.C.) R9-10-113(B)(1)(a)(i) states: "B. A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter...obtain one of the following as evidence of freedom from infectious tuberculosis: a. Documentation of a negative Mantoux skin test or other tuberculosis screening test that: i. Is recommended by the U.S. Centers for Disease Control and Prevention (CDC)." 2. A review of E3's personnel record revealed documentation of a negative two-step TB skin test. However, documentation of a TB screening was not available for review at the time of inspection. 3. In an interview, E2 acknowledged E3's personnel records did not contain documentation of TB screening at the time of the inspection.

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of the resident's orientation to exits from the assisted living facility, for one of seven sampled residents. 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 R2's medical record revealed documentation of the resident's orientation to exits from the assisted living facility was not available for review at time of inspection. 2. In an interview, E2 acknowledged R2's medical record did not contain documentation of R2's orientation to exits from the assisted living facility at the time of the inspection.