New Sunset Assisted Living

Based on record review and interview, the health care institution failed to develop a training program for all staff regarding fall prevention and fall recovery that included initial training. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. Review of E2’s personnel record revealed no initial fall prevention and fall recovery training. Based on E2’s hire date this training was required. 2. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on documentation review, record review, and interview, the chief administrative officer failed to implement tuberculosis (TB) infection control activities, including annually providing training and education related to recognizing the signs and symptoms of TB. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. Review of the Centers for Disease Control and Prevention (CDC) website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "All health-care workers (HCWs) should receive training on the prevention, transmission, and symptoms of TB disease that is appropriate to their work responsibilities and setting. Initial training should be provided to all new employees, with annual refresher training thereafter." 2. Review of E2’s personnel record revealed no initial TB training. Based on E2's date of hire this was required. 3. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on documentation review, observation, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of evidence of freedom from infectious tuberculosis (TB), as specified in R9-10-113, for two of four personnel sampled. The deficient practice posed a potential TB exposure 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 "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used." 3. The Compliance Officer observed E2 working at the time of the inspection. 4. Review of E2’s personnel record revealed a TB skin test dated November 6, 2025. However, there was no other TB skin test in E2’s record. Additionally, E2's record did not include documentation of assessing risks of prior exposure to infectious TB or determining if E2 had signs or symptoms of TB. Based on E2’s date of hire this was required. 5. Review of the facility “Employee Time Sheet” document revealed E2 worked throughout October from around 7 am to around 3:30 pm. 6. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on record review, documentation review, and interview, the manager failed to ensure that before providing assisted living services to a resident, a caregiver received orientation that was specific to the duties to be performed by the caregiver, for one of two personnel reviewed. The deficient practice posed a risk if the employees were unable to meet residents’ needs. Findings include: 1. The Compliance Officer observed E2 working as a caregiver at the time of the inspection. 2. Review of the facility “Employee Time Sheet” document revealed E2 worked throughout October from around 7 am to around 3:30 pm. 3. Review of E2’s personnel record revealed no documentation of completed orientation prior to providing services to the residents. Based on E2’s hire date this was required. 4. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a resident had a written service plan that included a description of the resident’s medical or health problems. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident. Findings include: 1. Review of R1’s medical record revealed a document titled “According to Service Plan Activities of Daily Living”. 2. In an interview, E2 indicated that the document titled, “According to Service Plan Activities of Daily Living” was the service plan for R1 and could not provide another document. 3. Review of R1’s medical record revealed a document titled, “According to Service Plan Activities of Daily Living". This document did not include the following: The level of care the resident was expected to receive The amount, type, and frequency of dressing, room maintenance, and laundry service. A description of the resident’s medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments. The signature of the resident or resident representative, manager of the facility, and a nurse or medical practitioner. 4. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on record review, and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record for one of one resident record reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. Review of R1’s medical record revealed a document titled, “According to Service Plan Activities of Daily Living” which revealed R1 received oral care, catheter care, “Comb Hair”, and dressing services. 2. In an interview, E2 revealed E2 documents the activities of daily living (ADL) in the progress notes. 3. Review of R1’s medical record revealed a document titled, “Progress Notes” which revealed on October 7, 2025 “[R1] had a good morning. [R1] had a pain I got [R1’s] morphine @ 8:10 am… had on BM @ 10:00 am and 1 more BM @ 3:00pm,” This entry does not tell if R1 received catheter care, hair combing, dressing, or oral care services. There were no other entries provided for October 7, 2025. Another entry dated, October 9, 2025 stated, “[E2] told manager that [R1] had 1 BM in the morning. Resident had [R1’s] family visiting [R1] [R1] ate a good lunch and looks good.” This entry does not tell if R1 received catheter care, hair combing, dressing, or oral care services. There were no other entries provided for October 9, 2025. 4. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on observation and interview, the manager failed to ensure medication stored by an assisted living facility was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to the physical health and safety of residents with access to the medication. Findings include: 1. The Compliance Officer observed an unlocked cabinet in the kitchen area. When the cabinet door was opened the Compliance Officer observed blue tape covering the locking mechanism, keeping the cabinet door from being locked. Inside the cabinet, the following medications were observed: - Quetiapine 25 MG - Pantoprazole Sodium - One unidentified pill was in a cup 2. In an exit interview, the findings were reviewed with E2, and no additional information was provided.