New Horizon Assisted Living.

“Based on documentation review and interview, the manager failed to ensure that policies and procedures were reviewed at least once every three years and updated as needed. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include:  1. A review of the facility's policy and procedure manual revealed an update date of April 22, 2022.  2. In an interview, E1 acknowledged that the policies and procedures were not reviewed at least once every three years and updated as needed.”

“Based on documentation review, observation, record review, and interview, the manager failed to ensure that a caregiver provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of two personnel sampled. The deficient practice posed a potential illness 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. While on-site for the compliance inspection, the Compliance Officer observed E3 at the facility, providing services to residents.  4. A review of E3's personnel record revealed a negative TB skin test that was less than 12 months old; however, no additional documentation of freedom from infectious TB was available for review. Based on E3’s date of hire, this documentation was required. 5. In an interview, E1 acknowledged E3 did not provide evidence of freedom from infectious TB as specified in R9-10-113.”

“Based on documentation review and interview, the manager failed to ensure the facility's 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 the facility's policies and procedures revealed that the facility's disaster plan was reviewed on May 5, 2024. However, no documentation of an additional review was available. 2. In an interview, E1 acknowledged that the facility's disaster plan was not reviewed at least once every 12 months.”