Renata's Home for the Elderly 2 INC

Based on documentation review and interview, the manager failed to ensure that 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 the facility's personnel schedule revealed there were two shifts. 2 . A review of the facility's disaster drills revealed documentation of a disaster drill conducted on the following dates and times: -June 4, 2025 on first shift; -June 4, 2025 on second shift. However, no additional documentation of disaster drills was available for Compliance Officer review. 3. In an interview, E1 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 manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for two of three residents sampled. The deficient practice posed a 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 R2's medical record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if R2 had signs or symptoms of TB. Based on R2's date of acceptance, this documentation was required. 3. A review of R3's medical record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if R3 had signs or symptoms of TB. Based on R3's date of acceptance, this documentation was required. 4. In an interview, the finding was reviewed with E2 and no additional information was provided.

Based on observation and interview, the manager failed to ensure a resident bathroom contained a slip-resistant surface in the shower. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed two shared bathrooms in the facility. Both bathrooms contained a shower. However, neither bathroom showers had a slip-resistant surface. 2. In an interview, E1 acknowledged the two bathroom showers in the facility did not contain slip-resistant surfaces.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the facility were stored in a locked area and inaccessible to residents. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed an unlocked cabinet in the bathroom located in R1's and R3's shared bedroom. The cabinet contained a bottle of "Lysol All-Purpose Cleaner", a canister of "Lysol Disenfectant Spray", a bottle of "LA's Totally Awesome Bleach", and a container of "Bar Keepers Friend Cleanser". 2. The Compliance Officer observed multiple ambulatory residents on the premises. 4. In an interview, E1 and E2 acknowledged the manager failed to ensure poisonous or toxic materials stored by the facility were stored in a locked area and inaccessible to residents.