Serendipity in the Sun II LLC.

“A. Except as provided in R9-10-808(B)(2), a manager shall ensure that a resident provides evidence of freedom from infectious tuberculosis: 1. Before or within seven calendar days after the resident's date of occupancy, and 2. As specified in R9-10-113.”

“F. A manager of an assisted living facility authorized to provide directed care services shall ensure that: 2. There is a 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 that meets one of the following: b. Provides access to an outside area: i. From which a resident may exit to a location at least 30 feet away from the facility, and ii. Controls or alerts employees of the egress of a resident from the facility; or”

“Based on record review and interview, the manager failed to ensure that a resident provided documentation of freedom from infectious Tuberculosis (TB) as specified in R9-10-113, for three of three residents reviewed. Findings include: 1. A review of R1, R2, and R3's medical records revealed no documentation of TB screening as required by R9-10-113.A.2.a 2. In an interview, E1 acknowledged that R1,R2, and R3 did not provide current documentation of freedom from infectious TB.”

“Based on 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. During the environmental inspection, when the patio door was opened, no alarm sounded to alert employees that a person was exiting the facility. In order to confirm the lack of alarm, the Compliance Officers (COs) exited and entered through the patio door three times. 2. During the environmental inspection, the COs observed that the patio door was equipped with a key lock mechanism however, it was not locked. 3. In an interview, E1 acknowledged there was not a means of exiting the facility that controlled or alerted employee of the egress of the resident.”

“Based on documentation review, record review, and interview, for one of four staff records reviewed, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not implemented. Findings include: 1. A review of facility documentation revealed a policy and procedure covering Fall Prevention. However, the policy and procedures did not include documentation covering Fall Recovery. 2. In record review, the personnel record for E3 did not include documention the staff received training on fall prevention and fall recovery. 3. During an interview, the findings were reviewed with E1 and O1, who acknowledged the policy and procedures for training personnel on falls did not include training on fall recovery, and the personnel record for E3 did not include documentation the personnel received training on fall prevention and fall recovery. E1 reported the staff were trained on fall recovery.”

“Based on record review, documentation review, and interview, for one of four caregivers reviewed, the manager failed to ensure a caregiver provided evidence of freedom from infectious tuberculosis (TB), as required by R9-10-113. The deficient practice posed a potential health and safety risk of TB exposure to residents and staff. Findings include: 1. In record review, the personnel records for E3 (hired as an assistant caregiver on December 18, 2023), did not include documentation the caregiver provided evidence of freedom from TB, as required. 2. In documentation review, the staffing schedule for March 2024, included documentation the assistant caregiver worked shifts at the facility. 3. During an interview, E1 acknowledged the personnel record for the assistant caregiver did not include documentation that E3 provided evidence of freedom from TB, as required by R9-10-113.”