Allegiance Assisted Living LLC

Based on observation, documentation review, and interview, the manager failed to ensure that a cat was vaccinated against rabies. The deficient posed a risk if a cat allowed into the facility did not meet the vaccination requirements. Findings include: 1. During the environmental inspection, the Compliance Officers observed O1. 2. A review of the pet records revealed no documentation of a rabies vaccination for O1. 3. During the exit interview, the findings were discussed with E1 and no additional information was provided.

Based on documentation review and interview, 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 if a staff member was unable to assist a resident who had fallen. Findings include: 1. A review of facility documentation revealed a document labeled "Fall prevention and recovery training programs." The program stated "All employees will have an initial training on fall prevention and recovery. After initial training, all employees will be required to attend continuing competency training on fall prevention and recovery at least every 12 months. Completion of the training shall be documented and included in the employee files." 2. A review of E1's personnel record revealed documented fall prevention and recovery training dated May 2022. However, E1's personnel record did not include a current annual training for fall prevention and recovery as required per the documented program. 3. A review of E2's personnel record revealed documented fall prevention and recovery training dated May 2022. However, E2's personnel record did not include a current annual training for fall prevention and recovery as required per the documented program. 4. In a joint interview, E1 and E2 acknowledged the documented fall prevention and recovery training program was not administered.

Based on documentation review and interview, the manager failed to ensure 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 documentation indicating the policies and procedures were last reviewed by the former owner on June 25, 2006. No additional documentation was available indicating the policies and procedures were reviewed at least once every three years. 2. In an interview, E1 acknowledged documentation was not available to indicate the facility's policies and procedures were reviewed at least once every three years.

Based on record review and interview, the manager failed to ensure a resident's written service plan was developed with assistance and review from the resident or resident's representative, for two of two residents sampled. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements related to resident care. Findings include: 1. A review of R1's medical record revealed a service plan dated in September 2023, for directed care services. However, the service plan did not include the signature of R1 or R1's representative to show the service plan was developed with assistance and review by R1 or by R1's representative. 2. A review of R2's medical record revealed a service plan dated in November 2022, for personal care services. However, the service plan did not include the signature of R2 or R2's representative to show the service plan was developed with assistance and review by R2 or by R2's representative. 3. In a joint interview, E1 and E2 acknowledged the service plans for R1 and R2 were not signed to indicate the service plans were developed with assistance and review by the residents or their representatives.