Willow Creek Assisted Living, LLC

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of freedom from infectious tuberculosis (TB), for one of three residents sampled. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of R1's medical record revealed documentation of a chest x-ray. The documentation stated "Impression: No acute cardiopulmonary disease indentified." However, documentation of a 2-step TB test or a TB blood test and TB screening, as required in Arizona Administrative Code (A.A.C. R9-10-113) was not available for review. 2. In an interview, E1 reported E1 thought a chest x-ray was acceptable documentation for TB requirements. E1 acknowledged R1's medical record did not contain valid documentation of freedom from infectious TB.

Based on documentation review, observation, and interview, the manager failed to ensure the means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort, controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if staff were unaware of the egress of a resident from the facility. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. During the environmental inspection of the facility, the Compliance Officer observed alerts placed on the front door and a door leading from the master bedroom to the back yard. However, the alerts on each door were turned off. The Compliance Officer also observed E2 turning on the alert placed on a side back door leading to the back yard. 3. In an interview, E1 acknowledged the means of exiting the facility did not control or alert employees of the egress of a resident from the facility at the time of the inspection.

Based on observation and interview, the manager failed to ensure a refrigerator used by an assisted living facility to store food or medication contained a thermometer, accurate to plus or minus 3 \'b0F, placed at the warmest part of the refrigerator. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed a refrigerator in the kitchen which stored food and medication. However, the refrigerator did not contain a thermometer, accurate to plus or minus 3 \'b0F, placed at the warmest part of the refrigerator. 2. In an interview, E1 acknowledged the kitchen refrigerator did not contain a thermometer accurate to plus or minus 3 \'b0F placed at the warmest part of the refrigerator.

Based on record review and interview, the manager failed to ensure a resident's orientation to the assisted living facility's evacuation plan and the route to be used was documented, for one of three current residents sampled. The deficient practice posed a risk if a resident was unaware of the route to be used to evacuate the facility in an emergency. Findings include: 1. A review of R1's medical record revealed a document titled "Resident Emergency Orientation." The document stated "I, (Blank) acknowledge that I have been orientated in these areas of emergency policy and procedures within twenty-four hours of admission" and included a signature and date line for a resident or resident's representative. However, the documentation was blank. 2. In an interview, E1 reported R1 had received orientation, and was not sure why the form was blank. E1 acknowledged R1's orientation to the assisted living facility's evacuation plan and the route to be used was not documented.