Sunset View Manor Senior Living LLC

Based on record review and interview, the health care institution failed to ensure that the facility documented tuberculosis infection control activities that include annually providing training and education related to recognizing the signs and symptoms of tuberculosis for one of six employees reviewed. The deficient practice posed a potential illness risk to residents. Findings Include: 1. A review of E4’s personnel record revealed no documentation of the required annual tuberculosis education/training. 2. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on observation and interview, the manager failed to ensure that medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to residents who were not prescribed the accessible medication. Findings Include: 1. During an environmental inspection of the facility with E1, the Compliance Officers observed an unlocked door leading to the sleeping area of the live-in staff. The Compliance Officers observed medications such as Advil and Famotidine within the sleeping area. 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 an employee provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of four caregivers reviewed. 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. Review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used." 3. Review of E2's personnel record revealed a negative TB skin test dated December 16, 2022. However, no additional documentation of freedom from infectious TB was available for review. Based on E2's hire date, this documentation was required. 4. In an interview, E1 acknowledged E2 did not provide documentation of freedom from infectious TB as specified in R9-10-113. Technical assistance on this rule was provided during the compliance inspection conducted on May 9, 2022.

Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for one of two residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. Review of R2's medical record revealed a current written service plan for directed care services dated September 20, 2023. This service plan stated "Catheter care...caregiver to empty bag twice a day and as needed". However, documentation was not available indicating this service was provided October 1st - present. 2. In an interview, E1 acknowledged R2's medical record did not include documentation of the above listed service and reported the services were provided as indicated in the service plan.