Golden Times LLC.

“Based on documentation review, record review, and interview, the manager failed to ensure employees provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113 for one of three personnel sampled. 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. Review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The webpage states, "If the Mantoux tuberculin skin test (TST) is used for baseline testing of health care personnel, use two-step testing." 3. A review of E3's personnel record revealed one TB skin test, risk assessment, and signs and symptoms screening. Based on E3's hire date, two TB skin tests were required. 4. In an interview, E2 acknowledged that E3 did not have a second TB test. This is a repeat deficiency from the compliance inspection conducted on May 24, 2023.”

“Based on record review and interview, the manager failed to ensure that, before or at the time of an individual’s acceptance by an assisted living facility, there was a documented residency agreement with the assisted living facility that included whether the manager or a caregiver was awake during nighttime hours, for two of two residents sampled. Findings include: 1. A review of R1 and R2's medical records revealed a residency agreement for both residents at the time of admission to the facility; however, there was no clear verbiage in the residency agreement that stated whether or not a caregiver was awake during nighttime hours. Based on R1's and R2's acceptance dates, this documentation was required. 2. In an exit interview, the findings were reviewed with E2, and no additional information was provided.  This is a repeat deficiency from the compliance inspection conducted on May 24, 2023.”