D' Vintage Place Assisted Living Home

Based on observation, documentation review, and interview, the manager failed to ensure documentation was maintained of the caregivers and assistant caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was no documentation to identify the staff that was present each day to ensure the health and safety of residents. Findings include: 1. While on-site for the compliance inspection, the Compliance Officers observed E2 working at the facility at approximately 1:00 PM. 2. A review of the facility's personnel schedule indicated E1 and E3 were scheduled to work on May 20, 2025. However, E3 was not on-site at the facility at the time of inspection. 3. A review of the facility's personnel schedule for May 2025 included AM and PM shifts, however, documentation of the times associated with these shifts was not available for review. 4. In an interview, E1 acknowledged the facility's personnel schedule did not include documentation of the caregivers who worked each day and the hours worked by each.

Based on documentation review, record review, and interview, the manager failed to ensure that a caregiver provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of five personnel sampled. The deficient practice posed a potential illness 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, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST (Mantoux Skin T est) is used for baseline testing, two-step testing is recommended for HCWs (Health Care Workers) whose initial TST results are negative. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read." 3. A review of E5's personnel record revealed a negative TB skin test that was less than 12 months old; however, no additional documentation of freedom from infectious TB was available for review. Based on E5’s date of hire, this documentation was required. 4. In an interview, E1 acknowledged that E5 did not provide evidence of freedom from infectious TB as specified in R9-10-113. This is a repeat deficiency from the compliance inspection conducted on November 5, 2021.

Based on observation, record review, and interview, the manager failed to ensure that the manager or a caregiver was present when a resident was in the home. Findings include: 1. While on-site for the compliance inspection, the Compliance Officers observed E1 walking across the street into the facility. 2. A review of E2's personnel record revealed that E2 was hired as an assistant caregiver. E2's personnel record did not contain documentation of a completed caregiver training program. 3. In an interview, E1 reported E1 had walked across the street to E1's home, leaving E2 in the facility alone. E1 acknowledged that E2 was not a trained caregiver and was the only staff member present in the home with the residents.

Based on record review and interview, the manager failed to ensure that a caregiver or assistant caregiver documented the services provided in the resident's medical record for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed activities of daily living dated May 2025. Between the 16th and 19th of May, there was no documentation of services provided. 2. In an interview, E1 acknowledged the services were provided but did not document R1's activities of daily living between the 16th and 19th of May.

Based on record review and interview, the manager failed to ensure medication was administered to a resident in compliance with the medication order and documented in the resident's medical record. Findings Include: 1. A record review of R1's medical record revealed a medication order dated May 31st, 2025, which listed various medications, including: Acetaminophen 500 mgs; 2 tabs one daily by mouth Benadryl 25mg; 1 tab once daily Buspirone 5mg; 1 tab twice daily, 2 tabs at bedtime by mouth Ropinirole 2mg; give 1 tab by mouth once daily at bedtime 2. A record review of R1's medication administration record (MAR) revealed no documentation that acetaminophen, Benadryl, and Ropinirole were given on May 19th, 2025, and no documentation that Buspirone was given at 12 pm and 8 pm on May 19th, 2025. 3. A review of R1's medication tray and medications revealed Ciprofloxacin being administered to the patient. However, Ciprofloxacin was not listed on the medication order. 4. A record review of R2's medical record revealed a medication order dated May 31st, 2025. Which lists various medications, including: Atorvastatin 40mg; give 1 tab by mouth daily at bedtime Donepezil 8mg give 1 tab by mouth once daily at bedtime Senna 8.6mg by mouth once daily 5. A record review of R2's medication administration record (MAR) revealed no documentation that Atorvastatin, Donepezil, or Senna were given on May 19th, 2025. 6. In an interview, E1 acknowledged that medication was not administered to a resident in compliance with the medication order and documented in the resident's medical record.

Based on documentation review, observation, and interview, the manager failed to ensure a means of exiting the facility controlled or alerted employees of the egress of a resident from the facility. Findings include: 1. A review of Department documentation revealed the facility was licensed to provide directed care services. 2. During the environmental inspection of the facility, the Compliance Officer observed the facility's back door did not have a way to alert employees of egress of a resident. 3. During the environmental inspection of the facility with E1, the Compliance Officer observed a sliding glass door in the master bedroom leading to the back yard. The sliding glass door did not have an alarm to alert employees of egress of a resident. 4. In an interview, E1 stated the alarm from back door had fallen off and needed to be replaced. E1 acknowledged the master bedroom back door did not have an alarm, and reported being unaware the door needed an alarm. E1 acknowledged the manager failed to ensure a means of exiting the facility controlled or alerted employees of the egress of a resident from the facility.