Reeves Foundation-Townley Homes

Based on record review and interview, the manager failed to ensure an employee provided documentation of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility, as specified in R9-10-113, for one of four employees reviewed. 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. 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 . A review of facility documentation revealed a staff schedule for October 28, 2024 to November 24, 2024. The schedule verified E4 scheduled to work the following dates: October 28, 2024; October 29, 2024; October 30, 2024; and October 31, 2024. 4. A review of E4's personnel record revealed a negative TB skin test dated October 21, 2024. A second TB skin test was revealed, however the second test was dated November 4, 2024. 5. In an interview, E5 acknowledged E4 did not provide documentation of freedom from infectious TB as specified in R9-10-113 on or before the date E4 began providing services at or on behalf of the assisted living facility.

Based on observation and interview, the licensee did not ensure the premises, it's structures, and furnishings are in a clean condition, free of odors, such as urine or rotting food, and 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: Three fans in resident bedrooms were not clean and in good condition; Two fans in resident bedrooms were missing the globe to cover the lightbulb; The flooring in the laundry room accessible by residents contained a hole and the edges lifted creating a trip hazard; and The porcelain of the sink in a resident bathroom was cracking and chipping causing sharp edges in the sink. 2. During an interview, E5 acknowledged the premises, it's structures, and furnishings were not in good repair that no object, equipment, or condition presented constituted a hazard.

Based on documentation review, record review, and interview, the manager failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. Review of E3's personnel record revealed no documentation of initial training for fall recovery. 2. Review of E4's personnel record revealed no documentation of initial training for fall recovery. 3. The Compliance Officer requested the facility's policy and procedure for fall prevention and fall recovery training, however, it was not available for review. 4. In an interview, E1 reported that the training company the facility used for personnel training confirmed that it did not have a fall recovery training available. E1 acknowledged E3's and E4's personnel record did not contain documentation that showed the health care institution had administered a training program for all staff regarding fall recovery.