Madeira Villa Assisted Living, LLC

Based on documentation review, record review, and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for two of two residents 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 R1's (admitted 2025) medical record revealed no documentation of a completed screening to assess R1's risk of prior exposure to infectious TB and if R1 had signs or symptoms of TB signed or dated by a medical practitioner, as required. Based on R1's date of admission, this documentation was required. 3. A review of R2's (admitted 2025) medical record revealed no documentation of a completed screening to assess R2's risk of prior exposure to infectious TB and if R2 had signs or symptoms of TB signed or dated by a medical practitioner, as required. Based on R2's date of admission, this documentation was required. 4. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on documentation review, observation, and interview, the manager failed to ensure that there was a means of exiting the facility that monitored or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A review of Department documentation revealed the facility was licensed to provide directed care services. 2. During an environmental tour of the facility, the Compliance Officers observed that the exit door from Room 4 was not equipped with a way to alert employees of the egress of a resident from the facility. 3. In an interview, E2 reported that the staff did not monitor the aforementioned door for egress. 4. In an exit interview, the findings were reviewed with E2, and no additional information was provided. Technical assistance was provided regarding this regulation during the compliance inspection conducted on November 14, 2024.

Based on documentation review and interview, the manager failed to ensure that policies and procedures were reviewed at least once every three years and updated as needed. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. A review of the facility's policy and procedure manual revealed documentation of a review of the facility's policies and procedures on January 1, 2018. However, no additional documentation of review was available for Compliance Officer review. 2. In an interview, E1 acknowledged that the policies and procedures were not reviewed at least once every three years and updated as needed.

Based on observation, record review, and interview, the manager failed to ensure that a resident or resident's representative consented to photographs of the resident before the resident was photographed, for two of two residents sampled. Findings include: 1. During an environmental tour of the facility, the Compliance Officers observed cameras used in the facility to monitor residents' whereabouts. 2. A review of R1's and R2's medical records did not contain a photographic consent form signed by the resident or resident's representative. 3. In an interview, E1 acknowledged R1's and R2's medical records did not contain consent to photographs by the resident or resident's representative before R1 and R2 were photographed.

Based on record review and interview, the manager failed to ensure the health care institution administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training, for one of three personnel sampled. The deficient practice posed a health and safety risk for residents. Findings include: 1. A review of E2's personnel record revealed documentation of Fall Prevention and Fall Recovery Training dated September 28, 2021. However, no documentation of further fall prevention and fall recovery training was available for Compliance Officer review. 2. In an interview, E1 reported the facility provided continued competency training regarding fall prevention and fall recovery annually. E1 acknowledged the facility failed to administer a training program for staff regarding fall prevention and fall recovery that included continued competency training.

Based on 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 one of three personnel sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A review of E2's personnel record revealed E2 completed training on recognizing the signs and symptoms of TB on June 10, 2023. However, documentation of additional training was not available for Compliance Officer review. 2. In an interview, E1 acknowledged E2's personnel record did not include documentation of annual training on recognizing the signs and symptoms of TB.