Casa De Vida Living LLC

Based on documentation review, record review, and interview, the health care institution failed to develop and administer a fall prevention and fall recovery program for all staff, which included initial training and continued competency training. Findings include: 1. A review of facility documentation revealed a fall prevention and fall recovery program. However, the program did not include initial training and continued competency training for staff. 2. A review of E1's, E2's, E3's, and E4's personnel records revealed no documentation of completion of fall prevention and fall recovery training. 3. In an interview, E1 acknowledged the facility's fall prevention and fall recovery program did not include initial training and continued competency training for staff, and could not provide documentation to indicate E1, E2, E3, and E4 completed initial training on fall prevention and fall recovery.

Based on record review and interview, the manager failed to ensure a resident's written service plan accurately included the amount, type, and frequency of assisted living services provided to the resident, for two of two sampled residents. Findings include: 1. A review of R1's medical record revealed a service plan dated March 4, 2023. The service plan reflected R1 would be provided assistance with dressing, maintenance of room, and laundry service. However, the amount and frequency of the aforementioned services was not documented. 2. A review of R1's medical record revealed a document titled "Activities of daily living sheet (ADL)" dated April 2023. The ADL sheet reflected R1 received assistance with dressing daily from April 1, 2023 to April 30, 2023, and assistance with laundry seventeen times in the month of April 2023. 3. A review of R2's medical record revealed a service plan dated December 16, 2023. The service plan reflected R2 would be provided assistance with dressing, maintenance of room, and laundry service. However, the amount and frequency of the aforementioned services was not documented. 4. A review of R2's medical record revealed a document titled "Activities of daily living sheet (ADL)" dated April 2023. The ADL sheet reflected R2 received assistance with dressing daily from April 1, 2023 to April 30, 2023, and assistance with laundry four times per week in the month of April 2023. 5. In an interview, E1 reviewed R1's and R2's medical records and acknowledged R1's and R2's service plans did not document the amount and frequency of all services provided to R1 and R2.

Based on record review and interview, the manager failed to ensure the requirements in R9-10-814(B)(2) were met for a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, for one of one sampled non-ambulatory residents. Findings include: 1. A review of R1's medical record revealed a service plan dated March 4, 2023, which stated "Non-ambulatory... Wheelchair/chair." R1's medical record contained a document titled "Authorization for Continued Residency" dated March 13, 2023. There was no prior documentation available regarding R1's authorization for continued residency. Based on R1's date of admission, R1 was required to meet this requirement upon admission. 2. In an interview, E1 and E2 acknowledged R1's determination was not completed on or before the date R1 was accepted to the facility.

Based on record review and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for one of two sampled residents. Findings include: 1. A review of R2's medical record revealed the following medication orders: -"Levothyroxine 25 mcg (micrograms) one tablet every other day" dated February 10, 2023; -"Levothyroxine 25 mcg one tablet daily before meals" dated March 12, 2023; -"Levothyroxine sodium 25 mcg Tab one tablet daily, discontinue all other orders" dated March 28, 2023; and -"Levothyroxine Sodium 50 mg (milligrams), take one tablet daily before meal" dated April 12, 2023. 2. A review of R2's medical record revealed a medication administration record (MAR) dated March 2023. The March 2023 MAR reflected R2 was administered "Levothyroxine 25 mcg" every other day from March 13, 2023 through March 31, 2023. 3. A review of R2's medical record revealed a MAR dated April 2023. The April 2023 MAR reflected R2 was administered "Levothyroxine 50 mg" from April 1, 2023 through April 30, 2023. 4. In an interview, E1 and E2 reviewed R2's March 2023 and April 2023 MARs and medication orders and acknowledged documentation did not reflect R2's "Levothyroxine" was administered according to R2's medication orders. This is a repeat citation from the previous on-site compliance inspection conducted on April 1, 2022.