Cactus-star Assisted Living LLC

Based on documentation review, record review, and interview, the manager failed to ensure that a manager provided evidence of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility, and as specified in R9-10-113, for one of four sampled employees. 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. A review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used." 3. A review of E2’s personnel record revealed one negative TB skin test dated May 9th, 2025. There was no additional documentation to indicate freedom from infectious TB. 4. In an interview, E1 acknowledged E2 did not have a second TB skin test and no additional documentation to show freedom from infectious TB in E2’s personnel records as specified in R9-10-113.

Based on observation and interview, for a facility that provided directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area that controlled or alerted employees of the egress of a resident from the facility. Findings include: 1. A review of the license issued by the Department revealed the facility was licensed at the directed care level. 2. During an environmental inspection of the facility, the Compliance Officer observed an alert on the door leading to the backyard. 3. The Compliance Officer observed a resident opening the door to come back inside, but the alert was not activated. 4. The Compliance Officer observed E3 turning the alert back on. 5. In an interview, E1 acknowledged that the door to the backyard did not alert employees of the egress of a resident from the facility. This is a repeat deficiency from the compliance inspection and complaint investigation conducted on June 28, 2024.

Based on observation and interview, the manager failed to ensure that food was protected from potential contamination. Findings include: 1. During an inspection of the kitchen, the Compliance Officer opened the oven door to reveal various food stored there, including leftover rice and bread. 2. During an inspection of the kitchen, the Compliance officer opened the pantry door to reveal an open bag of garlic, potatoes, rice, and onions on the floor. 4. During an inspection of the backyard, the Compliance officer observed an outside fridge with a pink bowl containing sealed meat that was defrosting. 5. In an interview, E1 acknowledged that food was not stored to protect from potential contamination.

Based on observation, record review, and interview, the manager failed to ensure the premises used at the assisted living facility were cleaned, and if applicable, disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection. Findings include: 1. During an environmental inspection of the kitchen, the Compliance officer found an unknown black substance underneath the sink. 2. A review of the facility's policies and procedures revealed no documentation regarding cleaning and disinfection. 3. In an interview, E1 acknowledged that the premises were not cleaned and disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection. This is a repeat deficiency from the complaint investigation conducted on June 3, 2022.

Based on observation, record 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 as organized instruction and information related to resident care and safety was not implemented. Findings include: 1. In observation, E2 was observed working at the facility during the inspection. 2. In record review, the personnel record for E2 did not include documention E2 received training on fall prevention and fall recovery. 3. During an interview, E4 reported E2 was a cook and housekeeper, and was unaware E2 required training on fall prevention and fall recovery. 4. This is a repeat deficiency from the compliance and complaint investigation conducted on October 10, 2023.

Based on observation, record review, documentation review, and interview, the manager failed to ensure at least the manager or a caregiver was present in the assisted living home when a resident was on the premises. The deficient practice posed a health and safety risk to residents who were on the premises with unqualified personnel. Findings include: 1. In observation, E1 was observed to be the only caregiver working at the facility, with E2 (housekeeper/cook), and 10 residents on the premises. 2. In documentation review, the June, 2024, "Work Schedule," was posted at the facility, and indicated E1 and E2 worked daily from 7:00am - 7:00pm, and E1 worked (alone) every night from 7:00pm - 7:00am. 3. In record review, E1's personnel record (date of hire May 13, 2022, and rehire November 18, 2023) included a caregiver certificate from "Comprehensive Training Services, LLC," dated April 9, 2012. E1's record indicated a fingerprint clearance card was obtained on August 8, 2022. 4. During an interview, E1 reported [E1] first came to Arizona in May 2022, from Las Vegas, and received caregiver training in Las Vegas, not in Arizona. E1 reported not being trained in Arizona. 5. A review of the website for caregiver certification verification revealed no caregiver certificate issued to E1. 6. During an interview, the findings were reviewed with E3 and E4, who acknowledged the facility is required to have at least a manager or caregiver present at the facility when residents are on the premises.

Based on documentation review, and interview, the administrator failed to document an alleged incident of neglect according to Arizona Revised Statutes (A.R.S.) \'a7 46-454. The deficient practice posed a risk as the Department was unable to assess if there was an immediate health and safety concern for residents who resided in the assisted living facility. Findings include: 1. In documentation review, the Department received a report from O2, which documented, "The adult victim resides in a facility and is being neglected. The RS (reporting source) was called out as the AV (alleged victim) had been yelling and making sounds for two days. When examined by the RS, the AV had bruises on ... arms and discoloration of ... legs. The Av's blood pressure and sugars were very low. The AV was transported to the closest facility, John C Lincoln..." 2. During an interview, O1 reported, "there were two caregivers on site, one was washing dishes, and a male caregiver (E1) showed O1 the resident, and then went to the common area and was on the phone. O1 requested further information from the caregiver (E1), who told O1 the resident had been screaming and yelling and making noises for the past two days. Normal baseline was "word salad," but was screaming and yelling and not making sense. (E1) gave O1 face sheet with hand written information, O1 had to request the medication list. O1 had to enter the handwritten resident information into O1's device, to make it legible, while O1's partner obtained R1's vitals. R1 was observed to be extremely pale, not following commands, legs had bruises, bruises on arms, lividity, low blood pressure, heart rate high and unstable, blood sugar 41, was not receiving hospice services, as far as O1 knew... Took R1 to a closer hospital then what was on the paperwork, due to R1's condition... was notified by APS (Adult Protective Services) that resident passed away at the hospital... 3. During an interview, O2 reported a visit was made to the facility, where O2 spoke with E1, who didn't provide information, and gave O2 E4's card, and said to contact E4, who was the manager. O2 reported the resident passed away at the hospital. 4. During an interview, E3 and E4 reported APS visited the facility, and the caregivers sent documentation to the APS investigator, as requested. E3 and E4 reported an incident report was documented on R1's condition, and the facility investigated the APS allegation; however, did not believe neglect had occurred. E4 acknowledged the facility did not document the investigation of the allegation of neglect, as required per R9-10-803.J.

Based on documentation review, and interview, for one resident death, the manager failed to provide written notification to the Department of a resident's unexpected death, according to A.R.S. \'a7 11-593. The deficient practice posed a risk, if the Department was not informed of a resident's death, and was unable to assess a potential danger to other residents at the facility. Findings include: 1. In documentation review, the Department received a complaint report regarding the care and services provided for R1. 2. During an interview, O2 reported R1 passed away after being transferred from the facility to the hospital. 3. In documentation review, Department records revealed the Department was not notified by the facility of R1's death. 4. During an interview, E1, E3, and E4 reported R1 was transferred to the hospital, where R1 passed away. E3 reported R1's death was unexpected, R1 was not receiving Hospice services, and R1's death was not reported because R1 was not at the facility at the time of the death. E4 acknowledged the facility was required to report a resident's unexpected death.

Based on observation, record review, documentation review, and interview, for one of three caregivers reviewed, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrator and Assisted Living Facility Managers (NCIA Board). The deficient practice posed a risk if a caregiver was not qualified to provide the required services, and the Department was provided false and misleading information. Findings include: 1. During the compliance and complaint investigation, E1 was observed to be the only caregiver working at the facility, with E2 (housekeeper/cook), and 10 residents on the premises. 2. In record review, E1's personnel record (date of hire May 13, 2022, and rehire November 18, 2023) included a caregiver certificate from "Comprehensive Training Services, LLC," dated April 9, 2012. E1's record indicated a fingerprint clearance card was obtained on August 8, 2022. 3. During an interview, E1 reported [E1] first came to Arizona in May 2022, from Las Vegas, and received caregiver training in Las Vegas, and not in Arizona. E1 reported not being trained in Arizona. 4. A review of the website for caregiver certification verification revealed no caregiver certificate issued to E1. 5. During an interview, the findings were reviewed with E3 and E4, who acknowledged E1's report that E1 did not participate in a caregiver training program in Arizona.

Based on observation, record review, documentation review, and interview, for one of three caregivers reviewed, the manager failed to ensure the facility had sufficient caregivers with the qualifications, experience, skills, and knowledge necessary to provide the assisted living services in the facility's scope of services, to meet the needs of a resident, and ensure the health and safety of a resident. The deficient practice posed a health and safety risk to residents due to the facility having insufficient and unqualified staff, to meet the needs of the residents. Findings include: 1. During the compliance and complaint investigation, E1 was observed to be the only caregiver working at the facility, with E2 (housekeeper/cook), and 10 residents on the premises. 2. In documentation review, the June, 2024, "Work Schedule," was posted at the facility, and indicated E1 and E2 worked daily from 7:00am - 7:00pm, and E1 worked (alone) every night from 7:00pm - 7:00am. 3. In documentation review, the Department received a report from O1, which documented, "... O1 was called out as R1 had been yelling and making sounds for two days. When examined by... O1, R1 had bruises on ... arms and discoloration of ... legs. R1's blood pressure and sugars were very low. R1 was transported to the closest facility, John C. Lincoln..." 4. During an interview, O1 reported there were two caregivers on site, one was washing dishes, and a male caregiver (E1) showed O1 the resident, and then went to the common area and was on the phone. O1 requested further information from the caregiver (E1), who told O1 the resident had been screaming and yelling and making noises for the past two days. Normal baseline was "word salad," but was screaming and yelling and not making sense. (E1) gave O1 face sheet with hand written information, O1 had to request the medication list. O1 had to enter the handwritten resident information into O1's device, to make it legible, while O1's partner obtained R1's vitals. R1 was observed to be extremely pale, not following commands, legs had bruises, bruises on arms, lividity, low blood pressure, heart rate high and unstable, blood sugar 41, was not receiving hospice services, as far as O1 knew... Took R1 to a closer hospital then what was on the paperwork, due to R1's condition... was notified by APS (Adult Protective Services) that resident passed away at the hospital... 5. In record review, E1's personnel record (date of hire May 13, 2022, and rehire November 18, 2023) included a caregiver certificate from "Comprehensive Training Services, LLC," dated April 9, 2012. E1's record indicated a fingerprint clearance card was obtained on August 8, 2022. 6. During an interview, E1 reported [E1] first came to Arizona in May 2022, from Las Vegas, and received caregiver training in Las Vegas, and not in Arizona. E1 reported not being trained in Arizona. 7. A review of the website for caregiver certification verification revealed no caregiver certificate issu

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months. The deficient practice posed a health and safety risk to residents and employees, if the employees were unable to implement the evacuation plan. Findings include: 1. In documentation review, the facility provided documentation evacuation drills were conducted every six months through October 13, 2023. No further documentation of an evacuation drill conducted since October 13, 2023, was provided. 2. During an interview, E3 and E4 reported the facility had two shifts. E4 reported the evacuation drills were conducted as required; however, the paperwork was all over the place. E4 acknowledged the documentation of evacuation drills was provided during the inspection, however, did not include documentation an evacuation drill had been conducted since October 13, 2023.

Based on record review, observation, and interview, for one of four residents reviewed, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan. The deficient practice posed a health risk to a resident who didn't receive showering or bathing, as indicated. Findings include: 1. In observation, R2 was observed in bed at the facility, and had a wound on the left lower leg, and a bandaged wound on the right lower leg. 2. In record review, R2's service plan (SP) (received personal care and medication administration services), dated February 19, 2024, documented R2 required assistance in all areas of activities of daily living, i.e., eating, oral care, dressing, bathing, sponge bath, toileting, etc, and was "Bed Bound." R2 had "wounds, skin will remain intact, improving,... keep resident's skin clean and dry, apply hydrating lotion, ensure good hygiene and nutrition, check resident's skin at every shower, bath, and PRN... "Sponge bath... Facility staff on the days shower is not given."- Bathing "Requires total care, CNA shower 2 x every week by facility staff as needed." 3. In record review, R2's "Activities of Daily Living Flowsheet," (ADL) dated June, 2024, included documentation R2 received a sponge bath on June 1, June 7, June 14, and June 20, 2024. R2's ADL form, dated May 2024, included documentation R2 received a sponge bath daily in May. 4. During an interview, R2 reported [R2] was confined to the bed, and unable to get up to take showers. R2 used to receive bed baths from Hospice; however, hadn't received a bed bath from anyone in a long time. R2 reported the facility caregivers didn't provide baths, and the Hospice worker changed [R2's brief] and then gave [R2] a wash cloth to wash [R2's] face. R2 did not receive a bed bath weekly, as indicated on the June, 2024, ADL record, and did not receive a bed bath daily, as indicated on the May, 2024, ADL record. 5. During an interview, the findings were reviewed with E4, who acknowledged R2 reported not having had a bed bath, or a shower, as indicated on R2's service plan.

Based on observation, and interview, the manager failed to ensure a caregiver encouraged residents to participate in activities planned according to subsection (E). The deficient practice posed a risk if residents were not offered opportunities and encouraged to participate in planned activities. Subsection (E) requires: E. A manager shall ensure that: 1. Daily social, recreational, or rehabilitative activities are planned according to residents' preferences, needs, and abilities; 2. A calendar of planned activities is: a. Prepared at least one week in advance of the date the activity is provided, b. Posted in a location that is easily seen by residents, c. Updated as necessary to reflect substitutions in the activities provided, and d. Maintained for at least 12 months after the last scheduled activity; 3. Equipment and supplies are available and accessible to accommodate a resident who chooses to participate in a planned activity; and 4. Multiple media sources, such as daily newspapers, current magazines, Internet sources, and a variety of reading materials, are available and accessible to a resident to maintain the resident's continued awareness of current news, social events, and other noteworthy information. Findings include: 1. In documentation review, the posted activity calendar titled, June 2024, indicated the activities to be provided on the day of the inspection were: chair exercise, watch TV, crafts and oldies music. Other activities on the calendar included dancing, bingo, scrabble, games, puzzle, story telling ball tossing, spelling bee, etc. 2. In observation, the facility had ten residents on the premises during the inspection. Four - six residents were observed sitting in the common area with the Television on, throughout the survey. No activities were observed to be provided. 3. During an interview, alert and oriented residents R4, R5, and R6, were observed in the common area throughout the day, and reported activities were not provided. The compliance officer asked the residents about the activities listed on the calendar, to which they replied no. 4. During an interview, the findings were reviewed with E4, who reported the residents were provided with activities of bingo and singing. 5. Technical assistance was provided during the compliance inspection conducted on October 10, 2023.

Based on record review, observation, documentation review, and interview, for two of four residents reviewed, the manager failed to ensure a caregiver documented the services provided in the resident's medical record. The deficient practice posed a risk if services provided for residents could not be verified, and the Department was provided false and misleading information. Findings include: 1. In observation, R2 was observed in bed at the facility, and had a wound on the left lower leg, and a bandaged wound on the right lower leg. 2. In record review, R2's service plan (SP) (received personal care and medication administration services), dated February 19, 2024, documented the following: diagnoses of Pyothorax, COPD Gilbert's Syndrome, Hypertension, Hypertensive Heart Disease, Thrombocytosis, and End Stage Renal. The SP documented CNA visits twice weekly and Nursing Visits 60 minutes once weekly. The SP had a box titled "Wound Clinic," which was left blank. The SP indicated R2 required assistance in all areas of activities of daily living, i.e., eating, oral care, dressing, bathing, sponge bath, toileting, etc, and was "Bed Bound." R2 had "wounds, skin will remain intact, improving, patient has seeing wound care nurse twice a week, see attached doctors order on file... keep resident's skin clean and dry, apply hydrating lotion, ensure good hygiene and nutrition, check resident's skin at every shower, bath, and PRN... "Sponge bath... Facility staff on the days shower is not given."- Bathing "Requires total care, CNA shower 2 x every week by facility staff as needed." 3. In record review, R2's "Activities of Daily Living Flowsheet," (ADL) dated June, 2024, included documentation R2 received a sponge bath on June 1, June 7, June 14, and June 20, 2024. R2's ADL dated May, 2024 included documentation R2 received a sponge bath daily. R2's ADL for May and June had a section titled, "Wound Care," which was blank, indicating no services provided for R2's wounds. 4. During an interview, R2 reported [R2] was confined to the bed, and unable to get up to take showers. R2 used to receive bed baths from Hospice; however, hadn't received a bed bath from anyone in a long time. R2 reported the facility caregivers didn't provide baths, and the Hospice worker changed [R2's brief] and then gave [R2] a wash cloth to wash [R2's] face. R2 did not receive a bed bath weekly, as indicated on the June, 2024, ADL record, and did not receive a bed bath daily, as indicated on the May, 2024, ADL record. R2 reported staff provided care for R2's leg wounds, as needed. 5. During an interview, the findings were reviewed with E4, who acknowledged R2 reported was not provided a bed bath, as was documented on R2's ADL record. E3 and E4 reported R2 received wound care services from an outside agency, twice weekly, and staff provided services for R2's wound on the days the agency did not visit. E3 and E4 acknowledged R2's ADL record did not include the services provided by the caregiv

Based on record review, documentation review, and interview, for one of four residents reviewed, the manager failed to ensure the service plan for a resident receiving personal care services included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections. The deficient practice posed a health and safety risk to residents, if staff were unaware of the skin maintenance services needed by a resident. Findings include: 1. In record review, R1's "Resident Initial Assessment," dated April 20, 2024, (received personal care services), documented ""Hx of breast cancer, HTN, Gerd, HOH, Malignant neoplasm of breast, R Hemiparesis, had "unchanged", wounds. The assessment indicated R1's skin was "Intact/Good Condition, Reddened, Pale, Warm, Dry, Moist, and Poor. Skin Condition: "Yes," impaired skin observed. Special Treatment and preventative measures: "patient has wound on ... head and there is liquid coming ... legs and arm has bruises and legs was swelling... stomach have rashes and redness..." Fed by staff, self help device needed, needed assistance with oral care, was incontinent, needed assistance with ambulating, bathing, dressing, grooming, toileting, transferring. "Skin integrity, no pressure sore,"Home Health Care: Have referred waiting to come and visit." "Resident was sitting in the wheelchair and ... legs was swelling, have bruises and redness... Arm was so fragile and easy to get bruises. R1's service plan did not include documentation of skin maintenance services provided for R1 to prevent and treat bruises, injuries, pressure sores and infection. 2. In record review, R1's "Activities of Daily Living Flowsheet," (ADL) indicated R1 was provided "daily skin check, apply daily non-medical lotion...; however, the ADL did not indicate skin maintenance services for bruising, rashes and wounds were provided for R1. A section titled, "Wound Care," was left blank. 3. In documentation review, the Department received a report from O1, which documented, "... O1 was called out as R1 had been yelling and making sounds for two days. When examined by... O1, R1 had bruises on ... arms and discoloration of ... legs. R1's blood pressure and sugars were very low. R1 was transported to the closest facility, John C. Lincoln..." 4. During an interview, O1 reported R1 was observed to be extremely pale, not following commands, legs had bruises, bruises on arms, lividity, low blood pressure, heart rate high and unstable, blood sugar 41... Took R1 to a closer hospital then what was on the paperwork, due to R1's condition... was notified by APS (Adult Protective Services) that resident passed away at the hospital... 5. During an interview, E1, E3 and E4 reported R1 had skin problems on acceptance. E1 reported [E1] gave R1 showers and observed R1's skin problems got worse, and did not report this to anyone. E3 and E4 acknowledged R1's service plan did not include skin maintenance services provided for R1, to prevent and treat bruises, injur

Based on observation, documentation review, and interview, for the facility which provided directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area which controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a health and safety risk to residents as an unlocked door provided access to the outside, without alerting employees. Findings include: 1. In documentation review, the facility was licensed at the directed level of care. 2. During an environmental inspection, the Compliance Officer observed the facility's front door, and back door leading to the backyard were unlocked, and did not control or alert employees of the egress of a resident from the facility 3. During an interview, the findings were reviewed with E4, who acknowledged the facility was licensed at the directed level of care, and the facility did not provide access to an outside area, which controlled or alerted employees of the egress of a resident from the facility.

Based on documentation review and interview, the manager failed to ensure an employee disaster drill was conducted on each shift at least once every three months and documented. The deficient practice posed a health and safety risk to residents if the employees were not trained to implement the facility's disaster plan. Findings include: 1. In documentation review, the facility provided documentation of disaster drills conducted through January 11, 2024, on the first and second shifts. No documentation was provided to indicate a disaster drill was conducted since January 11, 2024, on each shift at least once every three months. 2. During an interview, E3 and E4 reported the facility had two shifts. E4 reported the disaster drills were conducted as required; however, the paperwork was all over the place. E4 acknowledged the documentation of disaster drills was provided during the inspection, however, did not include documentation a drill had been conducted since January 11, 2024.

Based on observation and interview, the manager failed to ensure a resident bedroom was not used as a passageway to another sleeping area and storage area, which was not used as a passageway before October 1, 2013. Findings include: 1. During an environmental inspection, the surveyor observed two residents resided in a master bedroom in the facility. The master bath area was curtained off; the bathroom was filled with boxes and other stored items, and the closet was door was closed and blocked by a bed frame. 2. During an interview, E1 and E4 reported E1 slept in on a fold up mattress on the floor of the bathroom. E4 acknowledged the master bathroom was used for storage and for sleeping; and the residents' bedroom was used as a passageway to the area. 3. This is a repeat deficiency from the compliance and complaint investigation conducted on October 10, 2023.

Based on documentation review, record review and interview, the health care institution failed to provide appropriate first aid to a resident who had fallen, appeared to be uninjured, and was able to reasonably recover independently. The deficient practice posed a risk as the facility called 911 instead of providing first aid to a non-injured resident by assisting them off the floor after a fall. Findings include: 1. In documentation review, a review of facility documentation revealed the facility had a policy titled, "... Patient Safety Fall Prevention," which documented, "... In order for employees... to begin ... work and provided assistance to residents... for their living services, they will be ... asked to sign a facility form called "Affirmative duty of Care" which instates their concrete understanding of their duties for their residents' care:... 2. The Caregiver should attend Fall Prevention Training to School..." 2. In record review, two of five personnel records revealed no documentation of training in fall prevention and fall recovery. The personnel records for E3 and E5 included a certificate which indicated training was received in "Fall Prevention and Fall Recovery." 3. During an interview, R3 reported [R3] had a recent fall in the bathroom, while preparing to use the toilet. R3 reported [R3] was not hurt during the fall, and reported being uninjured to staff who were present; E3 and E5. R3 reported "they [staff] didn't try to get me up," and paramedics arrived and helped [R3] off the floor. R3 reported being ambulatory with the use of an assistive device. 4. During an interview, E3 reported "I didn't feel well," at the time of the incident, so did not attempt to assist R3 from the floor. 5. In record review, R3's medical record did not include documentation of the resident's fall and 911 contact. 6. During an interview, E1 reported facility personnel received training in fall prevention and fall recovery from an outside instructor. However, E1 was unaware if the personnel were trained to assist non-injured residents after a fall. E1 acknowledged first aid was not administered by facility staff. E1 reported staff on duty at the time may have panicked and called 911. E1 acknowledged the healthcare institution failed to provide appropriate first aid to a resident who was unable to reasonably recover independently.

Based on documentation review, record review, and interview, for two of five personnel reviewed, the manager failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk to the physical health and safety of residents, if all personnel were not trained in fall prevention and recovery. Findings include: 1. In documentation review, a review of facility documentation revealed the facility had a policy titled, "... Patient Safety Fall Prevention," which documented, "... In order for employees... to begin ... work and provided assistance to residents... for their living services, they will be ... asked to sign a facility form called "Affirmative duty of Care" which instates their concrete understanding of their duties for their residents' care:... 2. The Caregiver should attend Fall Prevention Training to School..." 2. In record review, the personnel records for E4 and E6, did not include documentation the staff had received fall prevention and fall recovery training. 3. In observation, E4 and E6 were observed working at the facility during the inspection. 4. During an interview, E1 reported facility personnel received fall prevention and fall recovery training from an outside instructor; however, acknowledged E4 and E6 did not receive the training.

Based on documentation review, record review, and interview, for one of three residents reviewed, who had a fall, the manager failed to ensure the facility's incident reporting policy was implemented. The deficient practice posed a risk if the facility did not maintain documentation of resident incidents, as required. Findings include: 1. In documentation review, a facility policy titled, "D. Incident Documenting and Reporting," documented, "... It is the policy of this Facility that any accident or incident that causes injury or could potentially have caused injury or harm to a resident is documented on an Incident Report form... Incidents must be investigated and documented within 24 hours of occurrence. The form includes the following information: 1. Name of resident involved, time and date of incident and a brief description of what happened. 2. Staff filling out the incident report form must include whether an injury was sustained and the nature of the injury. Staff must also include if medical attention was required.. 3. Any action that was taken by the staff at the time of the Incident/Accident and what actions the facility will take to ensure that the Incident/Accident does not occur again in the future. 4. Any appropriate individuals that were notified and what date/time they were notified, including the Resident's representative or emergency contact, Resident's Physician and any other persons required to be notified related to the resident's care." 2. During an interview, R3 reported [R3] had a recent fall in the bathroom, while preparing to use the toilet. R3 reported [R3] was not hurt during the fall, and reported being uninjured to staff who were present; E3 and E5. R3 reported "they [staff] didn't try to get me up," and paramedics arrived and helped [R3] off the floor. R3 reported being ambulatory with the use of an assistive device. 3. In record review, R3's medical record did not include documentation of the resident's fall and 911 contact. 4. During an interview, E1 reported having no documentation of R3's incident available for review.

Based on observation, record review and interview, for one of three residents reviewed, the manager failed to ensure a service plan included the care instructions for a resident receiving services from a home health service agency. The deficient practice posed a health risk to the resident if the caregiver did not know the home health (HH) care instructions. Findings include: 1. In observation, R1 was observed to be in bed. 2. During an interview, R1 reported being unable to walk or get out of bed, and reported [R1] had a wound on the buttocks which was being treated by a nurse. 3. During an interview, E2 and E3 reported R1 had recurring wounds, and was being treated for a wound on [R1's] buttocks for approximately two months. E2 and E3 reported a nurse visited one to two times a week over the last two months and communicated instructions. The nurse gave instructions for the facility's caregivers to change the bandage, and clean the area daily, and after incontinence, and to put Vanicream and Aquaphor on [R1's] legs and behind. 4. In record review, R1's medical record (received personal care and home health services) included a service plan dated July 24, 2023. The service plan did not include documentation R1 had a wound on the buttocks, and did not include care instructions provided from the HH agency nurse. 5. During an interview, E2 acknowledged R1's service plan did not include care instructions for R1; who received services from a HH agency. 6. This is a repeat deficiency from the compliance inspection conducted on September 15, 2022.

Based on record review, and interview, for one of three residents reviewed, the manager failed to ensure a resident had a written service plan that was reviewed and updated no later than 14 calendar days after a significant change in the resident's condition. The deficient practice posed a risk to residents, if the service plan did not accurately reflect the resident's condition and services to be provided for the resident. Findings include: 1. In observation, R1 was observed to be in bed. 2. During an interview, R1 reported being unable to walk or get out of bed, and reported [R1] had a wound on the buttocks which was being treated by a nurse. 3. During an interview, E2 and E3 reported R1 had a recurring wound, and was being treated for the wound on [R1's] buttocks for approximately two months. 4. In record review, R1's medical record (received personal care and home health services) included a service plan dated July 24, 2023. The service plan did not include documentation R1 had a wound on the buttocks. 5. During an interview, E1 acknowledged R1's service plan was not updated after a significant change in the resident's condition.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents included all individuals on the premises, except for a resident whose medical record contained documentation that evacuation from the facility would cause harm to the resident. The deficient practice posed a health and safety risk to residents and employees if the employees were unable to implement the evacuation plan. Findings include: 1. In documentation review, the facility's employee and resident evacuation drills were documented as conducted on May 19, 2023, and August 19, 2023. The documentation indicated R1 participated in the evacuation drills and required full assistance in wheelchair, 2. In observation, R1 was observed to be in bed. 3. During an interview, R1 reported being confined to the bed, and was unable to walk or get out of bed since an injury to [R1's] leg, which occurred over two years ago. R1 was observed and reported to be in the same condition during the prior inspection conducted on September 15, 2022. 4. In record review, R1's medical record did not include documentation that it would cause harm to evacuate R1. 5. During an interview, E1 reported R1 did not participate in the evacuation drills, due to being confined to the bed; however, "was oriented to the evacuation" process. E1 acknowledged the evacuation drill documentation is required to include the names of the residents not evacuated. E1 acknowledged all persons on the premises are to be evacuated except a resident whose record had documentation the evacuation would cause harm, and acknowledged R1's record did not include this documentation.

Based on observation, documentation review, record review, and interview, the manager failed to ensure documentation of each evacuation drill included an identification of residents who were not evacuated. Findings include: 1. In documentation review, the facility's employee and resident evacuation drills were documented as conducted on May 19, 2023, and August 19, 2023. The documentation indicated R1 participated in the evacuation drills and required full assistance in wheelchair. 2. In observation, R1 was observed to be in bed. 3. During an interview, R1 reported being confined to the bed, and unable to walk or get out of bed since an injury to [R1's] leg, which occurred over two years ago. R1 was observed and reported to be in the same condition during the prior inspection conducted on September 15, 2022. 4. During an interview, E1 reported R1 did not participate in the evacuation drills, due to being confined to the bed; however, "was oriented to the evacuation" process. E1 acknowledged the evacuation drill documentation was required to include the names of the residents not evacuated.

Based on observation and interview, the manager failed to ensure a resident bedroom was not used as a passageway to another sleeping area and storage area, which was not used as a passageway before October 1, 2013. Findings include: 1. During an environmental inspection, the surveyor observed R3 and R4's bedroom was the master bedroom in the facility. The master bath area was curtained off, the bathroom area was filled with boxes and other stored items, and the closet was observed to include a bed and personal belongings. 2. During an interview, R3 and R4 reported the closet was used by a caregiver. 3. During an interview, E3 reported [E3] lived and slept in the closet area, and acknowledged the personal belongings in the closet area were E3's. E2 reported the bathroom was used as storage, and the closet was occupied by E3. E2 acknowledged the bedroom where R3 and R4 resided was used as a passageway to access the storage area and E3's bedroom. E2 reported the room was occupied by E3 for approximately two months.