Legend Ddd Services - Alex Nsgh

Based on documentation review and interview, the health care institution did not initiate cardiopulmonary resuscitation (CPR) before the arrival of emergency medical services, to a resident who was nonresponsive or had a cessation of normal respiration. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1 . A review of facility documentation revealed an "Incident Report" from September 2023. The Incident Report documented R3 being found R3 face down on the floor, nonresponsive, and without pulse. The Incident Report documented 911 was contacted, paramedics arrived, resuscitation attempts failed, and paramedics called time of death. However, no documentation that CPR was initiated before the arrival of emergency medical services was available for review. 2 . In an interview, E6 reported the LPN on shift during the incident had not initiated CPR before arrival of emergency medical personnel due to the weight of R3. E6 reported the LPN is no longer with the agency. E6 acknowledged the health care institution did not initiate cardiopulmonary resuscitation (CPR) in accordance with its certification training for CPR before the arrival of emergency medical services, to a resident who was nonresponsive or had a cessation of normal respiration.

Based on documentation review, record review, and interview, the health care institution's chief administrative officer failed to ensure training and education related to recognizing the signs and symptoms of tuberculosis (TB) was provided annually to individuals employed by the health care institution for three of three personnel sampled. The health care institution failed to establish, document, and implement TB infection control activities including annually assessing the health care institution's risk of exposure to infectious TB. Findings include: 1. A review of E1’s, E2’s, E3's, E4's, and E5's personnel record revealed no documentation E1, E2, E3, E4, or E5 completed training on recognizing the signs and symptoms of TB was available for review. 2. A review of facility documentation revealed no documentation of annually assessing the health care institution's risk of exposure to infectious TB was available for review. 3. In an interview, E6 acknowledged training and education related to recognizing the signs and symptoms of TB was not provided annually to individuals employed by the healthcare institution. E6 acknowledged TB infection control activities including annually assessing the health care institutions risk of exposure to infections TB was not established, documented, and implemented.

Based on documentation review, record review, and interview, the administrator failed to ensure that a caregiver provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113 for five of five 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 E1's personnel record revealed a hire date of September 2023. E1's personnel record revealed no evidence of freedom from infectious TB was available for review. 4. A review of E2's personnel record revealed a hire date of February 2025. E2's personnel record revealed no evidence of freedom from infectious TB was available for review. 5. A review of E3's personnel record revealed a hire date of July 2024. E3's personnel record included a negative PPD skin test. However, no assessment of risks of prior exposure to infectious TB, determination of signs or symptoms of TB, or second PPD skin test was available for review. 6. A review of E4's personnel record revealed a hire date of March 2024. E4's personnel record included a negative PPD skin test. However, no assessment of risks of prior exposure to infectious TB, determination of signs or symptoms of TB, or second PPD skin test was available for review. 7. A review of E5's personnel record revealed a hire date of December 2024. E5's personnel record included a negative PPD skin test. However, no assessment of risks of prior exposure to infectious TB, determination of signs or symptoms of TB, or second PPD skin test was avail

Based on documentation review and interview, the administrator did not ensure a disaster plan was reviewed at least once every 12 months. Findings include: 1. A review of the facility’s documentation revealed documentation of the facility’s disaster plan being reviewed was not available for compliance officer review. 2. In an interview, E6 acknowledged the disaster plan was not reviewed at least once every 12 months.

Based on documentation review and interview, the administrator did not ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. Findings include: 1 . A review of facility documentation revealed no documentation of a disaster drill for employees conducted was available for review. 2 . In an interview, E6 acknowledged a disaster drill for employees was not conducted on each shift at least once every three months and documented.

Based on documentation review and interview, the administrator did not ensure an evacuation drill for employees was conducted on each shift at least once every three months and documented. Findings include: 1 . A review of facility documentation revealed the following evacuation drill was conducted: July 25, 2025 at 2:15PM; However, no documentation of evacuation drills for employees conducted on each shift every three months was available for review. 2 . In an interview, E6 acknowledged an evacuation drill for employees was not conducted on each shift at least once every three months and documented.

Based on documentation review and interview, the administrator did to ensure an evacuation drill for residents was conducted at least once each year on each shift and documented. Findings include: 1. In an interview, E1 reported the facility schedule consists of three shifts. 2. A review of facility documentation revealed documentation of the following evacuation drills were conducted: July 1, 2025 at 2:15PM However, no documentation of an evacuation drill for residents being once each year on each shift was available for review. 3. In an interview, E6 acknowledged an evacuation drill for residents was not conducted at least once each year on each shift and documented.