Legend Ddd Services - Pontiac

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. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A review of the facility’s documentation revealed the following evacuation drill was conducted: June 25, 2025 during the 12:00AM to 8:00AM shift. However, no evacuation drill documentation for the 8:00AM to 4:00PM or 4:00PM to 12:00AM shifts were available for review. 2. In an interview, E1 and E4 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 not ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A review of facility documentation revealed no documentation of disaster drills being conducted was available for review. 2. In an interview, E1 and E4 acknowledged a disaster drill for employees was not conducted on each shift at least once every three months and documented.

Based on documentation review, record review, and interview, the administrator failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident's admission and as specified in R9-10-113, for two of two residents sampled. The deficient practice posed a TB exposure risk to residents. 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 R1's (admitted August 2023) medical record revealed documentation of R1's freedom from infectious TB. However, no assessment of risks of prior exposure to TB was available for review. 3. A review of R2's (admitted May 2023) medical record revealed documentation of R2's freedom from infectious TB. However, no assessment of risks of prior exposure to TB was available for review. 4. In an interview, E1 and E5 acknowledged R1 and R2 did not provide evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the R1's and R2's admission.

Based on record review, documentation review, and interview, the health care institution's chief administrative officer did not 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 four personnel sampled. The health care institution did not establish, document, and implement tuberculosis (TB) infection control activities including annually assessing the health care institution's risk of exposure to infectious TB. The deficient practice posed a potential illness risk to residents and staff. Findings include: 1. A review of E2’s, and E3’s, and E4's personnel record revealed no documentation of training and education related to the signs and symptoms of TB provided annually was available for review. 2. A review of facility documentation revealed no assessment of the health care institution’s risk of exposure to infectious TB was available for review. 3. In an interview, E2 acknowledged E1's, E2's, and E3's personnel record did not include documentation of annual training on recognizing the signs and symptoms of TB. E1 acknowledged no assessment of the health care institution’s risk of exposure to infectious TB was documented.

Based on documentation review, record review, and interview, the administrator failed to ensure that a personnel member or an employee or volunteer who had or was expected to have direct interaction with a resident for more than eight hours a week provided evidence of freedom from infectious tuberculosis (TB) on or before the individual began providing services at or on behalf of the nursing supported group home and as specified in R9-10-113 for four 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 E2's personnel record revealed a hire date of July 2024. E2's personnel record included two negative TST within 12 months. However, no assessment of risks of prior exposure to infectious TB was available for review. 4. A review of E3's personnel record revealed a hire date of July 2024. E3's personnel record revealed no evidence of freedom from infectious TB was available for review. 5. A review of E4's personnel record revealed a hire date of July 2024. E4's personnel record included a negative TST within 12 months prior to hire. However, an assessment of risks of prior exposure to infectious TB and second TST was not available for review. 6. In an interview, E1 and E5 acknowledged E2, E3, and E4 did not provide evidence of freedom from infectious TB as specified in R9-10-113.

Based on observation and interview, the administrator did not ensure the premises, it's structures, and furnishings were in sufficiently good repair that no object, equipment, or condition present constitutes a hazard. Findings include: 1. During an environmental inspection, the Compliance Officers observed the following items needing repair: The blinds in a resident bedroom appeared to be damaged and missing a panel preventing resident privacy; and The fans in the facility appeared unclean with dust buildup. 2. During an interview, E1 acknowledged the premises, it's structures, and furnishings were not in good repair that no object, equipment, or condition presented constituted a hazard.