Sun Health La Loma Assisted Living

Based on documentation review, record review, and interview, the manager failed to ensure an employee provided evidence 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 two employee sampled. 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. 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. A review of E2's personnel record revealed there was no documentation of freedom from infectious TB. Additionally, there was no documentation of a risk assessment or signs and symptoms screening. Based on E2's date of hire, this documentation was required. 4. 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 a caregiver received orientation specific to the duties to be performed by the caregiver before providing assisted living services, for one of two caregivers sampled. The deficient practice posed a risk if the employees were unable to meet residents’ needs. Findings include: 1 . A review of E2's personnel record revealed there was no documentation of caregiver orientation specific to the duties to be performed by the caregiver before providing assisted living services. E2's date of hire was December 10, 2024. 2 . In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on documentation review and interview, the manager failed to establish, document, and implement policies and procedures to protect the health and safety of a resident to cover qualifications, including required skills and knowledge, education, and experience for employees and volunteers. The deficient practice posed a risk if employees did not have the skills and knowledge to meet the needs of residents. Findings include: 1. A review of the facility's policies and procedures revealed no documentation of a policy covering how a caregiver's or assistant caregiver's skills and knowledge would be verified and documented. 2. In an interview, E4 and E5 acknowledged a policy and procedure covering how a caregiver's or assistant caregiver's skills and knowledge would be verified and documented was not available for review at the time of the inspection.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included the individual's starting date and, if applicable, ending date of employment, for three of three personnel member sampled. Findings include: 1. A review of E1's, E2's, and E3's personnel records revealed the records did not include E1's, E2's, or E3's starting dates of employment. 2. In an interview, E4 and E5 acknowledged E1's, E2's, and E3's personnel records did not include the E1's, E2's, or E3's starting dates of employment.

Based on record review and interview, the manager failed to ensure a personnel record for each employee or volunteer included documentation of evidence of freedom from infectious tuberculosis (TB), if required for the individual according to subsection (A)(8), for one of three personnel sampled. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of E1's personnel record revealed documentation of a TB skin test showing freedom from TB and a baseline screening was not available for review. 2. In an interview, E4 and E5 acknowledged E1's personnel record did not include documentation of evidence of freedom from TB.