Great Heart Adult Assisted Living Home

Based on observation, documentation review, and interview, the manager failed to ensure that oxygen containers were secured in an upright position. The deficient practice posed a potential explosion or leak of a compressed gas. Findings include: 1. During an environmental tour, the Compliance Officer observed three oxygen tanks that were not secured by an oxygen tank holder in the closet of an unoccupied room. 2. A review of the facility’s policies and procedures revealed a policy titled "Environmental and Physical Plant Safety, includes Pest Control Program”. The policy stated, “Oxygen tanks will be stored in the upright position at all times, and secured by a chain.” 3. In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure a manager and caregiver provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for two of two 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 Test) 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 the facility’s policies and procedures revealed a policy titled "Infection Control, Contagious Diseases including COVID (upper respiratory illness) Tuberculosis (TB) Control and Screening”. The policy stated, “Before providing services to the residents, all new hires will be required to complete TB screening and a risk assessment on a facility form called 'Tuberculosis (TB) Screening and Risk Assessment”. 4. A review of E1’s personnel record revealed no documentation that assessed E1's risks of prior exposure to TB. 5. A review of E2’s personnel record revealed an initial TB skin test completed before hire. However, the second TB skin test documentation was not available for review. Based on E2’s date of hire, this documentation was required. 6. In an exit interview, the findings were discussed with E1 and no additional information was provided. 7. Technical assistance was provided regarding this regulation during the compliance inspection conducted on May 20, 2024.

Based on record review, documentation review and interview, the health care institution’s chief administrative officer failed to implement tuberculosis infection control activities that annually provided training and education related to signs and symptoms of tuberculosis to individuals employed, for two of two personnel sampled and conduct an annual assessment of the health care institution's risk of exposure to infectious TB. The deficient practice posed a potential illness risk to residents. Findings include: 1. A review of E1’s personnel record revealed documentation of tuberculosis signs and symptoms training on April 12, 2024. However, additional training documentation was not available for review. 2. A review of E2’s personnel record revealed documentation of tuberculosis signs and symptoms training on April 18, 2024. However, additional training documentation was not available for review. 3. A review of the facility’s policies and procedures revealed a policy titled "Infection Control, Contagious Diseases including COVID (upper respiratory illness) Tuberculosis (TB) Control and Screening”. The policy stated, “All individuals employed by the facility or providing volunteer services for the facility will be required to complete Tuberculosis (TB) Training and Education related to recognizing the signs and symptoms of tuberculosis upon hire and annually thereafter The facility will be assessed on an annual basis to determine TB risk.” 4. A review of the facility’s annual TB facility risk assessment documentation revealed no completed documentation of a TB facility risk assessment. 5. In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on record review, documentation review, and interview, the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training for two of two personnel sampled. The deficient practice posed a health and safety risk for residents. Findings include: 1. A review of E1’s personnel record revealed documentation of fall prevention and fall recovery training on April 15, 2022. However, additional training documentation was not available for review. 2. A review of E2’s personnel record revealed documentation of fall prevention and fall recovery training on April 18, 2024. However, additional training documentation was not available for review. 3. A review of the facility’s policies and procedures revealed a policy titled "Fall Prevention and Recovery”. The policy stated, “Fall Prevention and Recovery Training is required upon hire and at least every 12 months thereafter.” 4. In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on observation and interview, the manager failed to ensure foods requiring refrigeration were maintained at 41\'b0 F or below. The deficient practice posed a health risk to the residents. Findings include: 1. During the facility tour, the Compliance Officer observed the following in a kitchen cabinet: -an opened container of "Kroger Original pancake syrup" -an opened container of "P.F. Chang's Sesame Sauce" -an opened container of "Kikkoman Teriyaki Marinade and Sauce" These containers stated "Refrigerate after opening". 2. During an interview, E1 acknowledged foods were stored at room temperature and required refrigeration.

Based on documentation review, record review, and interview, the manager failed to ensure a resident medical record contained documentation of notification of the resident of the availability of vaccination for influenza (flu) and pneumonia, according to A.R.S. \'a7 36-406(1)(d), to two of two residents reviewed. The deficient practice posed a potential illness risk to residents. Findings include: 1. A.R.S. \'a7 36-406(1)(d) states "The department shall: Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a licensee for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director." 2. Review of R1's and R2's medical records revealed no current documentation showing the flu vaccination was offered or received. 3. In an interview, E1 acknowledged R1's and R2's medical records did not include current documentation showing the flu vaccination was offered or received.

Based on record review and interview, the manager failed to ensure a resident provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of two residents reviewed. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. Review of R2's medical record revealed no documentation of freedom from infectious TB was available for review. Based on R2's acceptance date, this documentation was required. 2. During an interview, E1 acknowledged R2 did not provide current documentation of freedom from infectious TB.