Senior Serenity Assisted Living

Based on documentation review and interview, the manager failed to submit a documented report to the governing authority per the frequency established in the facility quality management program. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1. Review of the facility's policies and procedures revealed a policy titled "Quality Management Program" reviewed and signed by E1 April 8, 2022. This policy stated "...10. Once a month the manager will report to the governing authority/licensee all the concerns about the delivery of services related to the resident's care and any change made or action taken as a result of the identification of a concern about the delivery of services related to resident's care..." 2. Review of facility documentation revealed a quality management report completed October 26, 2022, January 5, 2023, and April 18, 2023. 3. During an interview, E1 and E2 acknowledged the quality management documentation was not completed per the frequency establish in the policy and procedure. 4. This is a repeat deficiency from the compliance inspection conducted October 25, 2022.

Based on record review and interview, the manager failed to ensure a resident provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of two residents reviewed. 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. 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 acceptance date, this documentation was required. 3. In an interview, E1 and E2 acknowledged R2 did not provide documentation of a risk assessment of prior exposure to infectious TB or a determination if R2 had signs or symptoms of TB. 4. Technical assistance was provided on this Rule during the compliance inspection conducted October 25, 2022.

Based on documentation review, record review, and interview, the manager failed to ensure an entry in a resident's medical record was not changed to make the initial entry illegible. The deficient practice posed a risk to the residents' health and safety if the documentation in the medical records was not accurate and legible. Findings include: 1. Review of the facility's policies and procedures revealed a policy titled "Documentation in Resident Records (Including Electronic Records" that stated "...5. Errors in documentation will be corrected as follows:...3. Use of erasers, white out, scratched is not allowed..." 2. Review of R2's medical record revealed a document titled "Initial Physician Recommendation Form" dated August 17, 2023. This document contained white correction fluid over the individuals name, which rendered the initial entry illegible. 3. In an interview, E1 and E2 acknowledged R2's medical record contained correction fluid that rendered the initial entry illegible. 4. Technical assistance was provided on this Rule during the compliance inspection conducted on October 25, 2022.

Based on observation and interview, the manager failed to ensure hot water temperatures were maintained between 95\'b0 F and 120\'b0 F in the areas of a facility used by residents. The deficient practice posed a health and safety risk to the residents. Findings include: 1. During an environmental inspection of the facility with E1 and E2, the Compliance Officer observed the hot water temperature at 89.1\'b0 F in the hall bathroom. 2. In an interview, E1 reported the hot water went out on September 23, 2023. E1 and E2 acknowledged the hot water temperature was not maintained between 95\'b0 F and 120\'b0 F in the areas of a facility used by residents.

Based on documentation review, record review, and interview, the health care institution failed to establish, document, and implement tuberculosis (TB) infection control activities as specified in R9-10-113. The deficient practice posed a TB exposure risk to residents and staff. Findings include: 1. Review of facility's documentation revealed no policy and procedure that covered TB infection control activities. 2. Review of facility documentation revealed no documentation of an annual assessment of the health care institution's risk of exposure to infectious TB. 3. In an interview, E1 and E2 acknowledged an assessment of the health care institution's risk of exposure to infectious TB was not conducted. 4. Technical assistance was provided on this Rule during the compliance inspection conducted October 25, 2022.