Holbrook Senior Center Extended Care

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), as specified in R9-10-113, for two of two personnel sampled. 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 E1's personnel record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if E1 had signs or symptoms of TB. Based on E1's hire date, this documentation was required. 3. A review of E2's personnel record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if E2 had signs or symptoms of TB. Based on E2's hire date, this documentation was required. 4. In an exit interview, the findings were reviewed with E1 and E2 and no additional information was provided.

Based on record review and interview, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA) for one of ten personnel records sampled. The deficient practice posed a risk if E2 was not able to meet the needs of residents. Findings include: 1. Review of E2’s personnel record did not reveal the record of a valid caregiver certificate. There was a document in E2’s personnel record which showed how many credit hours E2 took. However there was no ALTP number to verify the training course. 2. Review of the facility’s work schedule revealed E2’s August 2025 work schedule: 8am - 4pm on Mondays and Tuesdays 12 midnight- 8am on Tuesdays, Wednesdays and Thursdays E2 had August 5th, 6th, 7th, and the 11th off. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of two residents sampled. The deficient practice posed a 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 R2's medical record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if R2 had signs or symptoms of TB. Based on R2's date of acceptance, this documentation was required. 3. In an exit interview, the findings were reviewed with E1 and E2 and no additional information was provided.

Based on record review and interview, the manager failed to ensure that before or at the time of acceptance of an individual, the individual submitted documentation that was dated 90 calendar days before the individual was accepted by the assisted living facility and included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints and was dated and signed by a medical practitioner or registered nurse, for two of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R1's medical record revealed no documentation that stated whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints. Based on R1’s acceptance date, this documentation was required. 2. A review of R2's medical record revealed no documentation that stated whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints. Based on R2’s acceptance date, this documentation was required. 3. In an exit interview, the findings were reviewed with E1 and E2 and no additional information was provided.

Based on documentation review and interview, the chief administrative officer failed to ensure that the health care institution established, documented, and implemented tuberculosis infection control activities. Findings include: 1. Review of facility policies and procedures failed to reveal documentation indicating that the health care institution had established and documented tuberculosis infection control policies and procedures. 2. During an interview, E2 acknowledged that the required documentation was not available for review.

Based on documentation review and interview, the manager failed to designate, in writing, a caregiver who was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present. Findings include: 1. Upon entry into the facility E2 and E3 were observed to be the only staff in the facility with 12 residents. 2. Review of the record for E2 revealed that she was a certified caregiver. 3. Review of the record for E3 revealed that she was not a certified caregiver. 4. Review of the delegation of authority statement and the employee schedule, revealed that E2 had not been designated to act as the manager designee in the managers absence. 5. During an interview, E2 acknowledged that documentation failed to indicate that a caregiver who was present on the facility premises had been designated to act as manager designee when the manager is not present.

Based on record review and interview, the manager failed to ensure that one of three sample resident records contained evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113. Findings include: 1. The record for R3 contained no documentation of freedom from TB. Based on the resident's date of acceptance, this documentation was required. 2. During an interview, E2 acknowledged that the record did not contain evidence of freedom from TB as specified in R9-10-113.

Based on record review and interview the health care institution failed to develop a training program for all staff regarding fall prevention and fall recovery. Findings include: 1. Review of facility documentation failed to reveal that the health care institution had developed a training program for all staff regarding fall prevention and fall recovery. 2. During an interview, E2 acknowledged the training program documentation was not available for review. This is a repeat deficiency from the compliance inspection conducted on February 8, 2023.

Based on record review and interview, the manager failed to ensure that for three of three sample resident records, a standardized emergency responder patient information form was completed and maintained for each resident. Findings include: 1. The record for R1 failed to contain the completed emergency responder patient information documentation. 2. The record for R2 failed to contain the completed emergency responder patient information documentation. 3. The record for R3 failed to contain the completed emergency responder patient information documentation. 4. During an interview, E2 acknowledged that the required documentation was not available for review.

Based on record review and interview, the manager failed to ensure that one of three sample resident records contained documentation of a written service plan that was reviewed and updated at least once every six months for a resident receiving personal care services. Findings include: 1. The record for R1 contained service plan reviews reflecting the following dates of completion: May 19, 2023 and January 30, 2024. 2. During an interview, E2 acknowledged the service plan documentation did not reflect that the plans were reviewed and updated at least once every six months.

Based on record review and interview, the chief administrative officer failed to ensure that the health care institution established, documented, and implemented tuberculosis infection control activities that included annually providing training and education related to recognizing the signs and symptoms of tuberculosis (TB) to individuals employed by the health care institution. Findings include: 1. Review of the record for E1 failed to reveal documentation indicating that annual training related to recognizing the signs and symptoms of TB had been completed. No TB training documentation was available for review. 2. Review of the record for E2 failed to reveal documentation indicating that annual training related to recognizing the signs and symptoms of TB had been completed. No TB training documentation was available for review. 3. Review of the record for E3 failed to reveal documentation indicating that annual training related to recognizing the signs and symptoms of TB had been completed. No TB training documentation was available for review. 4. During an interview, E2 acknowledged that the required documentation was not available.

Based on documentation review and interview, the chief administrative officer failed to ensure that the health care institution established, documented, and implemented tuberculosis infection control activities that included annually assessing the health care institution's risk of exposure to infectious tuberculosis. Findings include: 1. Review of facility documentation failed to reveal an annual assessment of the health care institution's risk of exposure to infectious tuberculosis. 2. During an interview, E2 acknowledged that the required documentation was not available for review.