Danila's Assisted Living

Based on observation and interview, the manager failed to ensure there was a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort that provides access to an outside area which controls or alerts employees of the egress of a resident from the facility. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officer observed the front door leading to the front yard had a double-sided key-locked deadbolt and an alert on the door. However, the key was inserted into the deadbolt on the inside, and the alert was turned off. 2 . During an environmental inspection of the facility, the Compliance Officer observed a sliding glass door leading to the backyard of the facility. The door had an alert. However, the alert was turned off. 3 . During an environmental inspection of the facility, the Compliance Officer observed a door leading from a resident bathroom to the backyard of the facility. The door has a double-sided key-locked deadbolt. However, the door was unlocked. 4 . In an interview, E2 acknowledged the doors did not have a functioning or engaged control or alert that alerted employees of resident egress.

Based on a documentation review and interview, the manger failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training. Findings include: 1. A review of facility documentation revealed a training program for all staff regarding fall prevention and fall recovery was not available for review at time of inspection. 2. In an interview, E2 acknowledged a training program for all staff regarding fall prevention and fall recovery was not available for review at time of inspection.

Based on documentation review, record review, and interview, the manager failed to ensure an employee provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of three sampled personnel members. 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 CDC website revealed a page titled "Baseline Tuberculosis Screening and Testing for Health Care Personnel". The page stated, "If the Mantoux tuberculin skin test (TST) is used for baseline testing of health care personnel, use two-step testing." The page further stated, "Administer first TB skin test following proper protocol...If the result is negative, a second TB skin test is needed...Retest the health care personnel 1 to 3 weeks after the first TB skin test result is read." 3. A review of E4's personnel record revealed one negative TB test dated January 15th 2024. However, a second TB test and TB screening was not available for review during the inspection. 4. In an interview, E2 acknowledged a second TB test and TB screening for E4 was not available for review during the inspection.