Sage House - 68

Based on documentation review, observation, record review, and interview, for two of six employees reviewed, the manager failed to ensure an employee provided evidence of freedom from infectious tuberculosis (TB), as required by R9-10-113. The deficient practice posed a potential health and safety risk of TB exposure to residents and staff. 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. In observation, E5 and E6 were observed working at the facility during the inspection. 4. In record review, E5's personnel record, included documentation of one negative TB skin test; however, did not include documentation E5 provided a second negative TB skin test. E6's personnel record, included documentation of one negative TB skin test; however, did not include documentation E6 provided a second negative TB skin test. 5. During an interview, E1 acknowledged the employees did not provide documentation of freedom from infectious TB, as required by R9-10-113.

Based on observation, record review, and interview, for one of two residents reviewed, the manager failed to ensure a resident's written service plan included the amount, type, and frequency of assisted living services being provided to the resident. The deficient practice posed a risk to the health and safety of a resident if the service plan did not specify the amount, type, and frequency of services to be provided by caregivers, as required by a resident. Findings include: 1. In observation, R1 and R2 were on site during the inspection. Both residents were observed sitting in a wheelchair. 2. In record review, R1's medical record included a service plan dated August 9, 2024. The service plan documented R1 required assistance with activities of daily living, i.e., bathing, toileting and incontinence care, transferring, mobility, grooming and hygiene. R1 had a history of falls, and limited mobility. The service plan did not include the amount, type and frequency of these services provided for R1. 3. During an interview, E1 reported R1 was provided with a monitor and a bed alarm, and was provided daily skin maintenance services, assistance with toileting, transfers, and walking, and acknowledged R1's service plan did not include the amount, type and frequency of services provided. 4. Technical assistance was provided during the compliance inspection conducted on September 14, 2023.

Based on observation, interview and record review, for one of two residents reviewed, the manager failed to ensure the facility did not accept or retain a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, unless the facility obtained a written determination from the resident's primary care provider (PCP) or other medical practitioner (MP); upon acceptance or upon the onset of the condition, and every six months thereafter, that stated the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services. The deficient practice posed a safety risk to a resident, if a facility retained a resident without the required authorization. Findings include: 1. In observation, R2 was observed in a wheelchair. 2. During an interview, R2 (alert and oriented) reported R2 was unable to ambulate even with assistance, and had not walked for the past six months, due to having normal pressure hydrocephalus (NPH). 3. In record review, R2's medical record did not include documentation of a written determination from the resident's PCP or MP, at the onset of the condition, that stated the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services. 4. During an interview, E1 acknowledged the facility did not obtain a written determination from the resident's PCP or MP, as required.

Based on documentation review, observation, and interview, for a facility that provided directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area which controlled 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 the license issued by the Department revealed the facility was licensed at the directed care level. 2. During an environmental inspection, the Compliance Officer observed a patio door in the common area, to the backyard did not control or alert employees of the egress of a resident. The door had an alarm that had been turned off. Another door in the dining area was unlocked and was not controlled and did not alert employees of the egress of a resident. R3 was observed to exit the patio door, to the backyard, and the alarm did not sound. A door in the "Gym room," was unlocked and was not controlled and did not alert employees of the egress of a resident. 3. During an interview, E1 acknowledged the facility had several doors that provided access to an outside area; however, were not controlled or did not alert employees of the egress of a resident from the facility.

Based on observation, and interview, the manager failed to ensure medication stored by the assisted living facility was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. Findings include: 1. During an environmental inspection with E1 and E6, the Compliance Officer observed the residents' medications were stored on a counter top, and in an unlocked cabinet in an unlocked pantry, with food and supplies. 2. During an interview, E1 and E6 acknowledged the residents' medications were not stored in a locked manner used only for medication storage, and inaccessible to a resident.

Based on documentation review and interview, the manager failed to ensure an employee disaster drill was conducted on each shift at least once every three months and documented. The deficient practice posed a health and safety risk to residents and employees, if the employees were unable to implement the disaster plan. Findings include: 1. During an interview, E1 and E6 reported the facility had three shifts; Monday - Thursday day shifts, Friday - Saturday day shifts and Monday - Sunday night shifts. 2. In documentation review, the facility did not have documentation of disaster drills conducted on the Friday - Saturday day shifts. The documentation indicated E5 and E6 worked the Friday - Saturday day shifts, and did not participate in any disaster drills during the prior year. 3. During an interview, E1 acknowledged the facility did not have documentation of disaster drills conducted on each shift at least once every three months.

Based on observation and interview, the manager failed to ensure toxic materials stored by the facility were stored in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident if toxic materials were accessible. Findings include: 1. During an environmental inspection with E1 and E6, the Compliance Officer observed the laundry room door was propped open with gallon containers of Bleach. The room contained toxic and poisonous materials; to include, but not limited to, Bleach, Scrubbing Bubbles, Lysol wipes, Window cleaner, Insect spray. A cabinet beneath the kitchen sink was unlocked and contained Easy Off oven spray and Windex. An unlocked storage room in the back yard contained several cans of paint. The Compliance Officer observed the caregivers were not present in the areas where the materials were observed to be unlocked. 2. During an interview, E1 and E6 acknowledged the toxic materials were not stored in a locked area, and inaccessible to residents.