Sedona Springs Assisted Living

Based on record review and interview, the chief administrative officer failed to implement tuberculosis (TB) infection control activities, which included an annual assessment of the health care institution’s risk of exposure to infectious TB. Findings include: 1. A review of facility documentation revealed an annual assessment of the facility's risk of exposure to infectious TB, dated July 22, 2024. However, evidence of documentation of an assessment conducted since July 2024 was unavailable for review. 2. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review and interview, the manager failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the licensee did not provide the Department with the requested documentation required by this Article. Findings include: 1. On September 26, 2023, the Compliance Officer requested the following documents during the on-site inspection: - Disaster drills for employees; and - Evacuation drills with employees and residents. 2. In an interview, E1, and E2 acknowledged this information was not provided to the Compliance Officer within two hours after a Department request.

Based on documentation review and interview, the manager failed to ensure 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 staffing schedule revealed two shifts: - 7:00 am - 7:00 pm (First Shift), and - 7:00 pm - 7:00 am (Second Shift). 2. A review of documentation titled, "Disaster Drill" revealed the following information: - April 27, 2023, time: 2:00 pm to 2:30 pm (first shift), - January 10, 2023, time: 9:00 am to 9:20 am (first shift), - January 10, 2023, time: 8:00 pm to 8:25 pm (second shift), There was no additional documentation or evidence to indicate a disaster drill was conducted on each shift at least once every three months and documented. This documentation was not provided to the Compliance Officer within two hours after a Department request. 3. In an interview, E1, and E2 reported doing the drills, however, the documentation was unavailable for review.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months. The deficient practice posed a risk as a way to exit the facility in the event of an emergency was not posted. Findings include: 1. A review of the facility's documentation revealed an evacuation drill for employees and residents was conducted on the following days; - April 27, 2023, at 9:00 am to 9:30 am; and - April 27, 2023, at 8:00 pm to 8:30 pm. There was no additional documentation or evidence to indicate an evacuation drill was conducted at least once every six months. This documentation was not provided to the Compliance Officer within two hours after a Department request. 2. In an interview, E1, and E2 reported doing the evacuation drills, however, the documentation was unavailable for review.