Family Loving Kare Central

Based on record review and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery. Findings include: 1. A review of E1's personnel file revealed E1 had been hired in April of 2024. However, documentation of initial and ongoing competency training in fall prevention and fall recovery was not available for review. 2. A review of E2's personnel file revealed E2 had been hired in October of 2021. However, documentation of initial and ongoing competency training in fall prevention and fall recovery was not available for review. 3. In an exit interview with E1, the finding was reviewed and no additional information was provided.

Based on record review and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident's date of occupancy and as specified in R9-10-113, for one of two resident records reviewed. Findings include: 1. A review of R1's medical record revealed a negative skin test for TB. However, a baseline screening form, to include an assessment of R1's risks of prior exposure to TB and a determination if R1 had signs or symptoms of TB, was not available for review. Based on R1's date of admission, a completed TB baseline screening was required. 2. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on record review and interview, the manager failed to ensure that medication administered to a resident was administered in compliance with a medication order for one of two resident records reviewed. 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 R1's medical record revealed a signed medication order dated September 26, 2025, for “TAMSULOSIN HCL 0.4 MG CAPSULE TAKE 1 CAPSULE BY MOUTH EVERY EVENING**HOLD FOR SBP LESS THAN 100**”. 2. A review of R1’s Medication Administration Record (MAR) dated November 2025 revealed R1’s blood pressure was checked daily at 8 AM and at 8 PM. However, Tamsulosin was administered at 5 PM daily, without checking R1’s blood pressure prior to administration. Tamsulosin was held on November 1, 2025, with the reason noted as, “WITHHELD PER DR/RN”, though there is no documentation to indicate a blood pressure measurement. 3. In an exit interview, the findings were reviewed 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 facility documentation revealed a disaster drill conducted on each shift in October 2024, January 2025, April 2025, and July 2025. No disaster drills from October 2025 were provided for review. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided. This is a repeat citation from the on-site compliance inspection conducted on October 26, 2023.

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. Findings include: 1. A review of the facility's work schedule revealed the facility had two shifts, from 7 a.m. to 7 p.m. and from 7 p.m. to 7 a.m. 2. A review of facility documentation revealed a disaster drill conducted on each shift, on January 20, 2023 and on September 10, 2023. 3. In an interview, E1 acknowledged disaster drills were not conducted and documented on each shift at least once every three months.

Based on observation and interview, the manager failed to ensure the premises and equipment used at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a direct health and safety risk to residents. Findings include: 1. The Compliance Officer observed a wooden deck in the backyard, which was accessible to residents. The Compliance Officer observed the wooden slats of the deck were deteriorated and splitting. The Compliance officer observed a hole in the deck where one wooden slat had broken. 2. In an interview, E1 acknowledged the premises were not free from a condition or situation that may cause a resident or other individual to suffer physical injury. E1 reported a repair was requested and residents usually use another patio.