Arrowhead Senior Living

Based on record review, documentation review, and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery, which included initial training and continued competency, for one of two employees sampled. The deficient practice posed a risk as the caregiver received no organized instruction or information related to physical health services provided to residents. Findings Include: 1. A review of E2’s personnel record revealed a hire date of December 8, 2025. Further review of E2’s record revealed no fall prevention and fall recovery training. Based on E2’s hire date, this documentation was required. 2. A review of the facility's documentation revealed a signoff sheet titled, “Education for Fall Prevention/Recovery.” The sheet was signed by personnel who received the training. E2's name and signature were not listed on the sheet. 3. A review of the facility's staff schedule revealed E2 provided services to the residents. 4. A review of the facility’s policies and procedures revealed a policy titled "Fall Prevention/Recovery" which stated, "Fall prevention education is provided and reviewed for all employees and reviewed at least every 12 months." 5. In an interview, E1 acknowledged that E2 did not have the required fall prevention and fall recovery training. 6. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on documentation review and interview, the health care institution's chief administrative officer failed to ensure the health care institution established, documented, and implemented tuberculosis (TB) infection control activities that included annually assessing the health care institution's risk of exposure to infectious TB. The deficient practice posed a potential risk of illness to residents. Findings include: 1. A review of the facility’s documentation revealed no annual facility risk assessment for TB was documented in 2025. 2. In an interview, E1 reported E1 believed the employee records of annual TB training and education related to recognizing the signs and symptoms of tuberculosis was sufficient for this requirement. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review and interview, the manager failed to ensure a resident’s medical record contains a medication order from a medical practitioner for each medication that is administered to the resident, for one of two residents sampled. The deficient practice posed a health and safety risk if a resident received medication and the Department was unable to verify an order for the medication. Findings include: 1. A review of R1’s medical record revealed a current service plan dated March 3, 2026. The service plan revealed R1 received medication administration. 2. A review of R1's medical record revealed a medication administration record (MAR) dated March 2026. The MAR documented the following medication was administered at 8:00 AM on March 2, 2026, and March 4, 2026: “ONDANSETRON 4 MG 1 TAB PO Q 6 HRS PRN. NAUSEA/VOMITING” 3. A review of R1’s medications revealed a medication bottle labeled “Ondansetron Tab 4 MG” containing a supply of the tablets. 4. A review of R1's medical record revealed no medication order from a medical practitioner for Ondansetron 4 mg tablet. No medication order was provided during the inspection. 5. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on record review, document review, and interview, the manager failed to ensure medication administered to a resident was documented in the resident’s medical record, for one of two residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R2’s current service plan, dated January 21, 2026, revealed R2 received medication administration 2. A review of R2’s medical records revealed a medication order dated January 15, 2026. The medication order revealed, “Sertraline 25 MG tablet, Take 1 tablet by mouth once daily for anxiety/mood.” 3. A review of R2’s medical records revealed a medication administration record (MAR) dated March 2026. The MAR revealed, “Sertraline 25 MG 1 Tab PO QD” was not documented as administered from March 1, 2026, to present. 4. A review of the facility’s policies and procedures revealed a policy titled, “Mediations and Treatments” which stated, “Documentation: 22. All current medications will be included on the individualized MAR that is completed at beginning of each month for each resident. The nurse, manager, trained caregiver or authorized individual that administered medications will sign off the medication for the date and time the medicine was givens to the resident and the medications taken by initialing the Medication Administration Record or completing the PRN Flow sheet.” 5. In an interview, E1 reported R2 was administered the medication daily, but E1 made a mistake and did not document it as administered. 6. In the exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for one of three residents reviewed. The deficient practice posed a health and safety risk. Findings include: 1. Review of R1's medical record revealed a current written service plan for directed care services. This service plan stated "Catheter care...caregiver to empty bag twice a day and as needed". However, in review of the Activities of Daily Living (ADLs) sheet, there was only documentation of this service being provided once a day for February 2025. 2. In an interview, E1 reported the catheter bag is emptied according to the service plan. E1 acknowledged R1's medical record did not include documentation of the above listed service.