New Horizon Assisted Living

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 an update date of April 22, 2022. 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 documentation review, observation, record review, and interview, the manager failed to ensure that a caregiver provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of two 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. While on-site for the compliance inspection, the Compliance Officer observed E3 at the facility, providing services to residents. 4. A review of E3's personnel record revealed a negative TB skin test that was less than 12 months old; however, no additional documentation of freedom from infectious TB was available for review. Based on E3’s date of hire, this documentation was required. 5. In an interview, E1 acknowledged E3 did not provide evidence of freedom from infectious TB as specified in R9-10-113.

Based on documentation review and interview, the manager failed to ensure the facility's disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. A review of the facility's policies and procedures revealed that the facility's disaster plan was reviewed on May 5, 2024. However, no documentation of an additional review was available. 2. In an interview, E1 acknowledged that the facility's disaster plan was not reviewed at least once every 12 months.

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 four residents' records reviewed. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. Based on the date of acceptance, one sampled resident's record contained no documentation of freedom from TB. 2. Review of R1's medical record contained no documentation of freedom from TB as specified in R9-10-113. 3. In an interview, E1 acknowledged this resident's TB was not in compliance with the requirements for freedom from TB as specified in R9-10-113.

Based on record review and interview, the manager failed to ensure that within 90 calendar days before or on the day the individual was accepted by an assisted living facility there was completed the required documented determination. This documentation should have included whether the individual required continuous medical services and continuous or intermittent nursing services; this was based on the date of acceptance, for three of three sampled residents' records reviewed which posed a health and safety risk. Findings include: 1. Review of R1's medical record found documentation of a pre-admission determination that did not include whether the individual required continuous medical services and continuous or intermittent nursing services. Based on the date of acceptance this was required. 2. Review of R3's and R4's medical records found documentation of a pre-admission determination that did not include whether the individual required continuous medical services and continuous or intermittent nursing services. This documentation was not completed within 90 calendar days before or on the day the individuals were accepted to the facility. Based on the dates of acceptance this was required. 3. In an interview, E1 acknowledged the 90-day determination documentation was not completed as required. Technical assistance was provide during the compliance inspection on June 10, 2022 .

Based on record review and interview, the manager failed to ensure that a resident's medical record contained documentation of notification of the availability of the vaccination for pneumonia according to A.R.S. \'a7 36-406(1)(d), which required the facility to make the vaccination available to the resident on site on a yearly basis; for one of one sampled resident's record reviewed who had resided at the assisted living facility for more than 12 months which posed a health and safety risk. Findings include: 1. Based on the date of acceptance, R2's medical record provided no documentation to indicate R2 had received the pneumonia vaccine. There was no other documentation available in R2's medical record to indicate the vaccine was offered, given, refused or contraindicated. Based on the resident's date of acceptance, this documentation was required. 2. In an interview, E1 acknowledged there was no documentation available the pneumonia vaccine had been made available to R2 during the past twelve months. This is a repeat deficiency from the compliance inspection conducted on June 10, 2022.

Based on record review and interview, the manager failed to ensure that for one of one sampled resident's medical record reviewed, who was unable to ambulate even with assistance, the resident's primary care provider (PCP) or other medical practitioner signed a determination stating that the residents' needs were being met. This determination was to be completed at least once every six months throughout the duration of the resident's condition to determine if the resident's needs could be met based upon a current resident examination and the assisted living facility's scope of services which posed a health and safety risk. The facility is licensed to provided directed care services. Findings include: 1. In an interview, E1 reported R2 was unable to ambulate even with assistance. 2. Based on the review of R2's medical record, R2 had been unable to ambulate for over a year. R2's record contained no documented determination for the past twelve months. This determination should have been based on the PCP or medical practitioner's current examination of the resident and the facility's scope of services that the resident's needs could be met. The service plan stated the resident required directed care services. 3. In an interview, E1 acknowledged there were no determinations available for review that had been completed at least every six months throughout the duration of the resident's condition.