Hope Assisted Living

Based on observation, record review, documentation review, and interview, the manager failed to ensure documentation was maintained of the assistant caregiver working each day, including the hours worked. 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. The Compliance Officer observed E4 working at the facility at the time of the inspection. 2. Review of E4's personnel record revealed E4 worked as an assistant caregiver and had a hire date of March 1, 2023. 3. Review of the August 2023, September 2023, and October 2023 personnel schedules revealed no hours worked for E4. 4. In an interview, E1 and E2 acknowledged documentation was not maintained of the assistant caregiver working each day, including the hours worked by E4.

Based on 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 employees. 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. Review of E4's personnel record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if E4 had signs or symptoms of TB. Based on E4's hire date, this documentation was required. 3. In an interview, E1 and E2 acknowledged E4 did not provide documentation of a risk assessment of prior exposure to infectious TB or a determination if E4 had signs or symptoms of TB. 4. Technical assistance was provided on this Rule during the compliance inspection conducted November 17, 2022.

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 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. Review of R2's medical record revealed no documentation of freedom from infectious TB. Based on R2's acceptance date, this documentation was required. 3. In an interview, E1 and E2 acknowledged R2 did not provide current documentation of freedom from infectious TB. 4. Technical assistance was provided on this Rule during the compliance inspection conducted November 17, 2022.

Based on record review and interview, the manager failed to ensure a written service plan included a summary of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments, for one of two residents reviewed. The deficient practice posed a risk if medical or health problems were not addressed by the assisted living facility. Findings include: 1. Review of R1's medical record revealed a written service plan for personal care dated September 1, 2023. However, this service plan did not include documentation of R1's medical or health problems. 2. Review of R1's medical record revealed a document titled "Medical Director Certification of Terminal Illness" from Mountain View Hospice dated August 7, 2023. This document stated R1 had a diagnosis of "CHF, CKD III, HTN, Angina, AFTT, and severe Protein Calorie Malnutrition". 3. In an interview, E1 and E2 acknowledged R1's service plan did not include documentation of R1's medical or health problems.

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a separate locked room, closet, cabinet, or self-contained unit. The deficient practice posed a risk to residents who could access the medication. Findings include: 1. During an environmental inspection of the facility with E2 and E3, the Compliance Officer observed Novolin unlocked in a box in the kitchen refrigerator. This box had a locking device, however the device was not locked. 2. During an observation, the caregivers were not accessing the medication at the time of arrival. 3. In an interview, E1, E2, and E3 acknowledged medication was stored unlocked. 4. This is a repeat deficiency from the compliance inspection conducted November 17, 2022.

Based on observation and interview, the manager failed to ensure toxic materials stored by the facility were stored in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental inspection of the facility with E2 and E3, the Compliance Officer observed Lysol disinfectant, Fabuloso, Wind Fresh laundry detergent, Scrubbing Bubbles, and Raid unlocked in the laundry room. The laundry door had a locking device, however the device was not locked. 2. During an observation, the caregivers were not accessing the toxic materials at the time of arrival. 3. In an interview, E1, E2, and E3 acknowledged toxic materials were stored unlocked. 4. This is a repeat deficiency from the compliance inspection conducted November 17, 2022.