Houston Creek Assisted Living, LLC

Based on documentation review and interview, the manager 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, E1 acknowledged that the required documentation was not available for review.

Based on record review and interview the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery as required in A.R.S. \'a7 36-420.01. Findings include: 1. Review of the record for E2 (hired November 7, 2016), failed to reveal documentation that fall prevention and fall recovery training had been administered. 2. Review of the record for E3 (hired December 3, 2023), failed to reveal documentation that fall prevention and fall recovery training had been administered. 3. During an interview, E1 acknowledged that training for fall prevention and fall recovery had not been administered to all staff.

Based on record review and interview, the manager failed to ensure that one of one sample personnel records, for personnel who work more than eight hours per week, contained evidence of freedom from infectious tuberculosis (TB), as specified in R9-10-113. Findings include: 1. The record for E3 (Caregiver) contained documentation indicating that one TB test was administered within the 12 months prior to the date of hire. No other TB test documentation conducted within the past 12 months was found in the record. Based on the employee's date of hire this documentation would be required. 2. During an interview, E1 acknowledged that the documentation did not reflect that the employee record contained evidence of freedom from TB as specified in R9-10-113.

Based on record review and interview, the manager failed to ensure that the health care institution 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 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. 2. 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. 3. During an interview, E1 acknowledge that the required documentation was not available.