View of the Mountains Assisted Living LLC

Based on record review and interview, the manager failed to maintain a standardized form for each resident to be provided at the time the emergency responder (EMS) was contacted, for four of four records sampled. The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident. Findings include: 1. A review of R1, R2, R3 and R4's medical records revealed no standardized EMS documentation. 2. In an interview, E1 reported that R1, R2, R3 and R4 did not have standardized EMS documentation. 3. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on documentation review, observation, and interview, the licensee implemented a modification of the facility, without an approval or amended license issued by the Department. The deficient practice posed a risk as the Department was unable to assess and approve the modification, as the facility did not submit an updated floor plan. Findings include: 1. Review of Department documentation revealed a floor plan for AL12608H. The document indicated the primary bedroom was one bedroom with an adjoining bathroom. Department documentation revealed no documentation the licensee submitted a request for approval for a modification to the physical plant, including the addition of one bedroom. 2. The Compliance Officer observed the primary bedroom was modified by splitting it into two separate rooms. The side that was the bedroom was being used as a resident room. The bathroom side was being used as employee quarters with no outer door with a lock. The only partition was a bath curtain hung on a curtain rod and signage that read, "Do not enter" "Employees only" and "Caution - No visitors Allowed". 3. In an interview, E1 reported E1 did not notify the Department of the modification of the primary bedroom. 4. In an exit interview, the findings were reviewed with E2 and no additional information was provided.

Based on record review, documentation review, and interview, the health care institution failed to establish, document, and implement tuberculosis (TB) infection control activities that included annual training and education related to recognizing the signs and symptoms of TB to individuals employed by the health care institution and an annual assessment of the health care institution's risk of exposure to infectious TB. The deficient practice posed a risk as the caregiver received no organized instruction or information related to TB surveillance and posed a TB exposure risk to residents and staff. Findings include: 1. A review of E1, E2, E3, and E4's personnel records revealed no documentation of training and education for recognizing the signs and symptoms of infectious TB had been completed. Based on the dates of hire, this documentation was required. 2. A review of the facility's documentation revealed no documentation of annually assessing the health care institution's risk of exposure to infectious tuberculosis. 3. In an exit interview, the findings were reviewed with E2 no additional information was provided.

Based on documentation review and interview, the governing authority failed to review and evaluate the effectiveness of the quality management program at least once every 12 months. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1. Documentation review revealed there was no documentation that the quality management program were reviewed and evaluated at least once every 12 months. 2. In an interview, findings were discussed with E2 and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure that policies and procedures were reviewed and updated at least once every three years. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. A review of facility documentation revealed a policy and procedure binder. The binder was last reviewed and signed by the previous manager. 2. In an exit interview, the findings were discussed with E2, and no additional information was provided.

Based on documentation review, 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 two caregivers (employees who had or was expected to have more than eight hours of direct interaction with residents). 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. Review of E1's personnel record revealed no documentation of assessing risks of prior exposure to infectious TB or documentation of determining if E1 had signs or symptoms of TB. 4. Review of E1's personnel record revealed no documentation of the results of a second tuberculosis test. 5. In an exit interview, the findings were reviewed with E2 no additional information was provided.

Based on record review, documentation review, and interview, the manager failed to ensure a caregiver’s or assistant caregiver’s skills and knowledge were verified and documented before the caregiver or assistant caregiver provided physical health services or behavioral health services, and according to policies and procedures for one of four sampled. The deficient practice posed a risk if the employees were not qualified to provide the required services. Findings include: 1. A review of E4’s personnel record revealed that E4 was hired as a caregiver on October 28, 2025. The personnel record did not contain documentation verified skills and knowledge as the document had not been completed or signed by the manager. 2. A review of E4’s personnel record revealed that E4 was hired as a caregiver on October 28, 2025. The personnel record did not contain documentation of the employee orientation as the document had not been completed or signed by the manager. 3. During the environmental inspection, the Compliance Officer observed the of personnel schedules for November 1, 2025 and it revealed that E4 had been working at the facility, and was scheduled to work for the entire month of November 2025. 4. In an interview, E1 provided documentation from E4's past employer that contained an incomplete form for "New Employee Orientation Skill Set and Orientation. Employee demonstrates Understanding and Skills and Knowledge". None of the listed skills and know were boxes were checked off but it included the trainer's signature and date. 5. In an interview, E1 provided documentation from E4's past employer that contained an Employee Skills and Knowledge Checklist and Employee New Hire Orientation checklist completed and signed on June 27, 2023. 6. In an exit interview, the findings were reviewed with E2 and no additional information was provided.

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 four 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 R1's medical record revealed no documentation of assessing risks of prior exposure to infectious TB or documentation of determining if R1 had signs or symptoms of TB. 3. In an exit interview, the findings were reviewed with E2 no additional information was provided.

Based on record review and interview, the manager failed to ensure a documented residency agreement included the manager’s signature and date signed for three of four residents sampled. The deficient practice posed a risk if the resident was not informed of the terms of residency. Findings include: 1. A review of R2, R3, and R4's medical records revealed residency agreements that were unsigned by the manager. Based on R2, R3, and R4's acceptance date, this documentation was required. 2. In an exit interview, the findings were reviewed with E2 and no additional information was provided.

Based on observation, record review, and interview, the manager failed to ensure that a resident or the resident's representative consented to photographs of the resident before the resident was photographed, for two of four residents sampled. The deficient practice posed a risk as a resident's rights were violated. Findings include: 1. During an environmental tour of the facility, the Compliance Officers observed cameras used in the facility to monitor residents' whereabouts. 2. A review of R1, R2 and R3's medical records revealed no documentation of a photographic consent form signed by the resident or the resident's representative. 3. In an exit interview, the findings were reviewed with E2 and no additional information was provided.

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a separate locked room, closet, cabinet, or self-contained unit. The deficient practice posed a risk to residents who could access the medication. Findings Include: 1. During an environmental inspection of the facility with E2, the Compliance Officer observed the following: In the unlocked employees' quarters, Acetaminophen, Acetaminophen PM, Ibuprofen, and Calmoseptine ointment 2. In an exit interview, the findings were reviewed with E2 and no additional information

Based on documentation review and interview, the manager failed to ensure the disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. A review of facility documentation revealed the last disaster plan review was completed on January 20, 2023. 2. In an exit interview, the findings were reviewed with E2 and no additional information was provided.

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 the disaster plan. Findings include: 1. A review of the disaster drills revealed that the last disaster drill was conducted during the AM shift of March 1, 2025 and no additional documentation was available for review. 2. In an exit interview, the findings were discussed with E2 and no additional information was provided.

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 if employees were unable to implement the evacuation plan. Findings include: 1. A review of the facility evacuation drills revealed an evacuation drill conducted and documented for December 2024. However, there was no documentation of an evacuation drill conducted after December 2024. 2. In an exit interview, the findings were discussed with E2 and no additional information was provided.

Based on record review and interview, the manager failed to ensure that a resident received orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility, for three of the four residents sampled. The deficient practice posed a risk if a resident was unaware of the evacuation path to be used in an emergency. Findings include: 1. A review of R2, R3, and R4's medical records revealed no documentation of orientation to the exits of the facility. 2. In an exit interview, the findings were reviewed with E2 and no additional information was provided.

Based on observation and interview, the manager failed to ensure that poisonous or toxic materials stored by the assisted living facility were maintained in a locked area and were inaccessible to residents. The deficient practice posed a risk to the physical health and safety of residents. Findings Include: 1. During an environmental inspection of the facility with E2, the Compliance Officer observed the following: In the main bathroom, a bottle of Febreze on top of the sink In the unlocked employees' quarters, Revlon hair dye, Lysol disinfect spray, Clorox toilet bowl cleaner, CLR, and Cloralen concentrated bleach 2. In an exit interview, the findings were reviewed with E2 and no additional information was provided.