Agave Assisted Living Home II

Based on a documentation review, record review and interview, the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk of personnel was not trained to prevent or recover a resident in the event of a fall. Findings include: 1. A review of facility documentation revealed a training program for fall prevention and fall recovery was not available for review. 2. A review of E1's and E2's personnel records revealed initial training and continued competency training in fall prevention and fall recovery was not available for review. 3. In an interview, E1 acknowledged a training program for fall prevention and fall recovery training was not available for review. E1 further acknowledged that personnel members had not completed initial and continued competency training and reported to be unaware of this requirement.

Based on a record review and interview, the manager failed to ensure that a resident had a written service plan when initially developed and when updated, is signed and dated by the manager, for one of three residents sampled. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of R2's medical record revealed a current written service plan dated July 7, 2023, which indicated the resident received directed care services. However, the service plan was not signed and dated by the manager. 2. During an interview, E1 acknowledged R2's service plan was not signed and dated by the manager.

Based on an observation and interview, the manager failed to ensure a means of exiting the facility has controls or alerts employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed the front door and a door leading from the common area to the back yard. The Compliance Officer observed both doors did not have a mechanism to alert employees of the egress of a resident from the facility. 2. In an interview, E1 acknowledged that there was mechanism to alert the staff of a resident leaving the facility.

Based on an observation and interview, the manager failed to ensure oxygen containers were secured in an upright position. The deficient practice posed risk of a potential explosion or leak of a compressed gas. Findings include: 1. During a environmental inspection of the facility, the Compliance Officer observed in R1's room, the closet contained seven unsecured oxygen containers. 2. In an interview, E1 acknowledged the seven oxygen containers in R1's room closet were not secured in an upright position.