Bella Vista Assisted Living Home, LLC.

“Based on documentation review and interview, the manager failed to ensure that an employee provided documentation of freedom from infectious Tuberculosis (TB) as specified in R9-10-113, for E4.   Findings include:   1. A documentation review of the facility's Policies and Procedures Manual revealed a policy titled, "Tuberculosis ("TB") Testing", which stated, "The TB test must be BOTH administered AND read prior to the individual being accepted as a resident, providing services to residents, or moving into the facility, as appropriate."   2. In an interview, E2 revealed that E4 did not have proof of a negative TB test or screening.   3. In an interview, E2 acknowledged that E4 did not provide documentation of freedom from infectious TB prior to providing services at or on the behalf of the assisted living facility.”

“Based on observation, record review and interview, the manager failed to ensure that a personnel record for each employee or volunteer was maintained throughout the individual’s period of providing services in or for the assisted living facility. The deficient practice posed a risk as required information for a personnel member could not be verified.   Findings include:   1. Upon entry into the facility, the Compliance Officer was greeted by E4 who was the only employee at the facility. 2. A review of personnel records revealed that E4 did not have a record available for review.   3. In an interview, E2 revealed that E4 did not have a personnel record because the employee was temporarily covering for E3. 4. In an interview, E2 acknowledged a personnel record for E4 was not available.”

“Based on observation, documentation review, and interview, the manager failed to ensure a designated caregiver was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present on the assisted living facility premises. The deficient practice posed a risk as no individual was designated to act on behalf of the governing authority in the onsite management of the assisted living facility.   Findings include:   1. Upon arrival at the facility, the Compliance Officer was greeted by E4, who was the only employee on-site. 2. A documentation review of the manager designation form listed E2 and E3 as authorized designated managers in the absence of E1. 3. In an interview, E2 revealed that E4 was not listed as a designated employee. E2 revealed that E4 was a temporary employee who was covering for E3.   4. In an interview, E2 acknowledged that no manager or designee was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present on the assisted living facility premises.”

“Based on record review, documentation review and interview, the manager failed to ensure the facility did not retain a resident who was confined to a bed or chair without meeting the requirements in R9-10-814(B)(2), at least once every six months throughout the duration of the resident's condition, for one of two residents sampled who were confined to a bed or chair because of an inability to ambulate even with assistance.  1. A review of R1's service plan revealed that the resident was receiving Directed Care services and was wheelchair bound. 2. A review of the “Certification for Non-Ambulatory Residents to Reside in the Group Home” form for R1 was completed by the resident's physician on October 22, 2022.   3. A review of the “Approval of Continued Residency” form for R1 was last completed by the physician on August 13, 2024. In parenthesis, the form reads, "Completed by Doctor ever six months'   3. In an interview, E2 acknowledged that the manager failed to ensure that a physician examined the resident at least once every six months throughout the duration of the resident's condition.”