Home Sweet Home

Based on documentation review and interview, the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery to include initial training and continued competency training in fall prevention and fall recovery. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not developed. Findings include: 1. A review of the facility documentation revealed an undated document titled "Falls Prevention for Caregiver." The training did include fall recovery. However, the training program did not include the initial training and continued competency training requirement. 2. A review of E1's and E2's personnel records revealed initial training in fall prevention and recovery was not available for review. In an interview, E1 acknowledged the facility's fall prevention and fall recovery training program did not include the initial training and continued competency training requirement.

Based on observation and interview, the manager failed to ensure an individual residing in the assisted living home, who was not a resident, a manager, a caregiver, or an assistant caregiver and who was over 12 years of age or older, provided evidence of freedom from infectious tuberculosis (TB), as specified in R9-10-113. The deficient practice posed a TB exposure risk to residents. Findings include: 1. The Compliance Officer observed O3 and O4 on the premises of the assisted living home. 2. In an interview, E1 reported O3 and O4 were E1's grandchildren and resided at the facility. 3. The Compliance Officer requested to review O3's and O4's evidence of freedom from infectious TB as specified in R9-10-113. 4. In an interview, E1 reported O3 and O4 had evidence of freedom from infectious TB, however, the documention was not provided for review. Technical assistance was provided on this Rule during the onsite compliance inspection completed on July 6, 2022.

Based on record review and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of two residents sampled. The deficient practice posed a TB exposure risk to residents. Findings include: 1. A review of R1's (admitted in 2021) medical record revealed a chest x-ray dated in April 2023. The chest x-ray stated "CXRAY instead of TB test." However, the medical record revealed evidence R2 had a history of a positive skin test or other TB screening test recommended by the Centers for Disease Control and Prevention (CDC) was not available for review; and the chest x-ray was not an infectious TB screening test. 2. In an interview, E1 acknowledged R1 did not provide current documentation of freedom from infectious TB in compliance with R9-10-113.

Based on observation, record review, and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed an accessibility risk to residents who were not prescribed the accessible medication. Findings include: 1. The Compliance Officer observed two ambulatory residents on the premises. 2. The Compliance Officer observed Tamsulosin HCL 0.4 mg capsule medication bottle, belonging to R1, on the kitchen counter. 3. The Compliance Officer observed a night table in R1's unlocked bedroom contained Latanoprost eye drops and Timolol ophthalmic solution. 4. A review of R1's medical record revealed a medication order dated in March 2023 for the above mentioned medications. 5. In an interview, E1 acknowledged the medication was not stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.

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. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. A review of facility documentation revealed a disaster plan review dated July 6, 2023. However, 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. 2. In an interview, E1 acknowledged the disaster plan review did not include documentation of a critique of the disaster plan review; and if applicable, recommendations for improvement. This is a repeat deficiency from the onsite compliance inspection completed on July 6, 2022.

Based on observation and interview, the manager failed to ensure at least one common bathroom accessible from a common area contained paper towels in a dispenser or a mechanical air hand dryer. Findings include: 1. The Compliance Officer observed a common bathroom in the facility used by residents. However, the bathroom did not contain paper towels in a dispenser or a mechanical air hand dryer. 2. In an interview, E1 acknowledged the common bathrooms did not contain paper towels in a dispenser or a mechanical air hand dryer. 3. The Compliance Officer observed E1 put paper towels in a dispenser in the bathroom. Technical assistance was provided on this Rule during the onsite compliance inspection completed on July 6, 2022.

Based on observation and interview, the manager failed to ensure a swimming pool gate was locked when not in use. Findings include: 1. The Compliance Officer observed a swimming pool on premises contained water. However, the padlock on the self-closing, self-latching gate was not locked. 2. In an interview, E1 acknowledged the swimming pool gate was not locked. Technical assistance was provided on this Rule during the onsite compliance inspection completed on July 6, 2022.