Casa Theresita III

Based on record review, documentation review, and interview, the manager failed to ensure that a personnel record for each employee included continued competency training in fall prevention and fall recovery for two of two employees sampled. The deficient practice posed a risk if an employee received no organized instruction or information related to physical health services provided to residents. Findings Include: 1. A review of E1’s and E2's personnel records revealed documentation of continuing education for fall prevention and fall recovery training, dated in 2024 or 2025, was not available for review. 2. In an exit interview, the findings were reviewed with E1 and no additional information was provided. This is a repeat deficiency from the on-site compliance and complaint inspection conducted on October 30, 2024

Based on record review and interview, for two of two sampled residents, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113. Findings include: 1. A review of R1's medical record revealed a negative test for TB. However, documentation of baseline screening to include a risk assessment and symptom screen were not available for review. 2. A review of R2's medical record revealed a complete baseline screening for TB. However, the baseline screening was conducted 18 days after R2's date of occupancy. 3. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on observation and interview, the manager failed to ensure a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort, monitored or alerted 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 an environmental tour of the facility, the Compliance Officer observed a side door, located on the north side of the facility. The Compliance Officer observed the door was equipped with a door alarm, however, the alarm did not sound when the door was opened. 2. In an interview E1 reported the battery must have died on the door alarm and it was replaced immediately. 3. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on documentation review and interview, the governing authority failed to administer a training program for all staff regarding fall prevention and fall recovery to include continued competency training. Findings include: 1. A review of E2's personnel record revealed documentation of continued competency training in fall prevention and fall recovery was not available for review. 2. In an interview, E1 acknowledged E2's personnel record did not include documentation of continued competency training in fall prevention and fall recovery.

Based on record review and interview, the manager failed to ensure before or at the time of an individual's acceptance by the assisted living facility, there was a documented residency agreement with the assisted living facility which included the manager's signature and date signed, for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed a documented residency agreement. However, the residency agreement had not been signed and dated by the manager. 2. In an interview, E1 acknowledged the manager had not signed and dated the residency agreement for R1 before or at the time of R1's acceptance.

Based on record review, documentation review, and interview, the manager failed to ensure when a resident had an emergency resulting in the resident needing medical services, a caregiver documented the date and time of the incident; a description of the incident; the names of individuals who observed the incident; the action taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the incident from occurring in the future, for one of two residents reviewed who had an incident resulting in the resident needing medical services. Findings include: 1. A review of R1's medical record revealed R1 was a resident for two days in September 2024. However, the medical record did not include a discharge date, a progress note, or any other documentation of R1's discharge from the facility. 2. A review of facility documentation revealed an incident report regarding R1 was not available for review. 3. In an interview, E1 reported R1 had a mental health crisis the day after admission and E1 had to call for the mobile acute crisis team to come and transport R1 to a psychiatric facility for evaluation. E1 reported there was no disclosure prior to admission of R1's need for behavioral health services. E1 acknowledged an incident report for R1 regarding the behavioral health crisis and R1 subsequent emergency transportation to a psychiatric facility was not available for review.