Devon Gables Rehabilitation Center, LLC

Based on record review, and interview, the health care institution's chief administrative officer failed to ensure the health care institution documented, and implemented tuberculosis (TB) infection control activities required in R9-10-113.A.2.a-f. Findings include: 1. A review of E2 personnel record revealed a baseline screening and first-step Mantoux skin test (TST) conducted at the time of E2's employment at the facility. However, a second-step TST was not available for review. 2. A review of R1’s medical record revealed documentation of a risk assessment and symptom screening, conducted by a registered nurse, 11 months prior to R1's date of acceptance, and a second risk assessment and symptom screening, signed by the facility manager, four months after R1's date of acceptance. However, a negative TB test, dated within twelve months prior to R1's date of acceptance or up to seven days after R1’s date of acceptance, was not available for review. 3. In an interview, E1 acknowledged E2 and R1 did not have completed documentation of freedom from infectious TB within the required timeframes. Technical assistance was provided for this rule during the on-site compliance and complaint inspection conducted on April 24, 2024.

Based on record review and interview, the manager failed to maintain the original residency agreement in a resident's medical record, for two of two sampled residents. Findings include: 1. A review of R1's and R2's medical records revealed a residency agreement was not available for review. 2. In an interview, E1 and E2 acknowledged the original residency agreements were not available for review. E2 reported in the past, the resident would retain the agreement and the facility would historically copied a few of the pages, such as the signature page, for the facility's record.

Based on record review, interview, and record review, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for one of two sampled residents. Findings include: 1. A review of R1's medical record revealed a service plan, dated February 6, 2024, for directed care services including medication administration. 2. A review of R1's medical record revealed an order, dated March 26, 2024 , for "Losartan Potassium, 25 mg daily at HS, hold for SBP 100 for HTN." 3. A review of R1's medical record revealed a medication administration record (MAR) dated April 2024. The MAR indicated Losartan had not been administered between April 1 and April 7, 2024, or on April 21, 2024. The MAR indicated Losartan had been administered on April 8, 2024 through April 20, 2024, and on April 22, 2024, and April 23, 2024. However, the MAR did not indicate R1's blood pressure had been checked or documented prior to administration. 4. In an interview, E1 and E2 acknowledged Losartan had not been administered to R1 in compliance with a medication order.

Based on documentation review, observation, and interview, the manager failed to ensure the assisted living center had a license or permit as a food establishment under 9 A.A.C. 8, Article 1. Findings include: 1. During the on-site inspection, the Compliance Officer requested to review the facility's food establishment permit. However, a permit was not provided for review. 2. The Compliance Officer observed a food service and dining area on the premises included a warming cabinet, refrigerator, and small kitchen area. 3. In an interview, E1 and E2 acknowledged the assisted living center did not have a separate food establishment permit. E2 reported all food is cooked in a licensed commercial kitchen located in the skilled nursing section of the facility and reported food is only kept warm, minimally prepared, stored, and served in the assisted living dining room. E2 reported the facility's food establishment is inspected annually by the Pima County Health Department, however, each separate dining area did not have its own permit. Technical assistance for this rule was provided during the on-site compliance inspection conducted on April 19, 2023.