Catarina's Care Home

Based on record review and interview, the health care institution failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. Review of E1's personnel record revealed E1 had a hire date of October 1, 2024. The personnel record did not include documentation that showed E1 completed fall prevention and fall recovery training. 2. In an exit interview, findings were discussed with E1 and no additional information was provided.

Based on documentation review, observation, and interview, the manager failed to ensure there was a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort, that provided access to an outside area, and 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. Review of the license issued by the Department revealed the facility was authorized to provide directed care services. 2. During the environmental inspection, the Compliance Officer observed that the back door leading to the outdoors did not alert when opened. The alert mechanism appeared to be broken and missing a piece that would make the alert sound. 3. In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure a disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. A review of the facility's Disaster Relocation Plan revealed the disaster plan was last reviewed on June 30, 2023. 2. A review of the facility's policies and procedures revealed a policy titled "Emergency and Safety" that stated, "2. The disaster required in subsection (A)(1) is reviewed and the review is documented at least once every 12 months..." 3. In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A review of the employee's work schedule revealed the facility had two shifts: day and evening. 2. A review of the facility's disaster drills revealed a drill conducted on the following dates and times: September 3, 2024 - 9:15 AM September 3, 2024 - 2:40 PM September 2, 2025 - 7:30 AM 3. In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on observation and interview, the manager failed to ensure that a rechargeable fire extinguisher was serviced at least once every 12 months, and had a tag attached to the fire extinguisher that specified the date of the last servicing and the identification of the person who serviced the fire extinguisher. The deficient practice posed a risk if safety measures were not in place to protect residents in a fire. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed two fire extinguishers that contained no inspection tag, and the proof of purchase receipts were dated October 5, 2021 and July 16, 2024. 2. In an exit interview, the findings were reviewed with E1 and no additional information was added.

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 to include the manager's signature and date signed, for one of two residents sampled. Findings include: 1. A review of R1's (admitted in 2023) medical record revealed a documented residency agreement. However, the residency agreement was not signed and dated by E1. 2. In an interview, E4 acknowledged R1's residency agreement did not include the manager's signature or the date signed.

Based on record review and interview, the manager failed to ensure a resident had a written service plan, when initially completed, signed and dated by the resident or resident's representative and the manager, for two of two residents sampled. Findings include: 1. A review of R1's (admitted in 2023) medical record revealed a service plan dated in June 2023 for directed care services. However, the service plan was not signed and dated by the resident's representative or the manager. 2. A review of R2's (admitted in 2023) medical record revealed a service plan dated in March 2023 for personal care services. However, the service plan was not signed and dated by the resident. 3. In an interview, E4 acknowledged the service plan for R1 had not been signed and dated by R1's representative or the manager, and R2's service plan had not been signed and dated by the resident.

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of assisted living services provided to the resident, for one of two residents sampled. The deficient practice posed a risk as services provided could not be verified against a service plan. Findings include: 1. A review of R1's medical record revealed a service plan dated in June 2023 for directed care services. The service plan stated R1 was to receive assistance in activities of daily living for the following service: -Undergarments: Dependent, check brief every 2-3 hours 2. A review of R1's activities of daily living sheet, dated July 2023, revealed documentation to indicate R1 received assistance with the above mentioned service was not available for review. 3. In an interview, E2 reported R1 received assistance with the above mentioned service, however, the service was not being documented.

Based on documentation review and interview, the manager failed to ensure a disaster plan review required in (A)(2) was documented to include the time of the disaster plan review; a critique of the disaster plan review; and if applicable, recommendations for improvement. Findings include: 1. A review of facility documentation revealed a disaster plan review dated June 30, 2023. However, the disaster plan review did not include the time of the disaster plan review; a critique of the disaster plan review; and if applicable, recommendations for improvement. 2. In an interview, E4 acknowledged the disaster plan review did not include documentation of the time of the disaster plan review; a critique of the disaster plan review; and if applicable, recommendations for improvement.