Serendipity in the Sun II LLC

Based on record review and interview, the manager failed to ensure that a resident provided documentation of freedom from infectious Tuberculosis (TB) as specified in R9-10-113, for three of three residents reviewed. Findings include: 1. A review of R1, R2, and R3's medical records revealed no documentation of TB screening as required by R9-10-113.A.2.a 2. In an interview, E1 acknowledged that R1,R2, and R3 did not provide current documentation of freedom from infectious TB.

Based on observation and interview, the manager failed to ensure the 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, controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if staff were unaware of the egress of a resident from the facility. Findings Include: 1. During the environmental inspection, when the patio door was opened, no alarm sounded to alert employees that a person was exiting the facility. In order to confirm the lack of alarm, the Compliance Officers (COs) exited and entered through the patio door three times. 2. During the environmental inspection, the COs observed that the patio door was equipped with a key lock mechanism however, it was not locked. 3. In an interview, E1 acknowledged there was not a means of exiting the facility that controlled or alerted employee of the egress of the resident.

Based on documentation review, record review, and interview, for one of four staff records reviewed, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not implemented. Findings include: 1. A review of facility documentation revealed a policy and procedure covering Fall Prevention. However, the policy and procedures did not include documentation covering Fall Recovery. 2. In record review, the personnel record for E3 did not include documention the staff received training on fall prevention and fall recovery. 3. During an interview, the findings were reviewed with E1 and O1, who acknowledged the policy and procedures for training personnel on falls did not include training on fall recovery, and the personnel record for E3 did not include documentation the personnel received training on fall prevention and fall recovery. E1 reported the staff were trained on fall recovery.

Based on record review, documentation review, and interview, for one of four caregivers reviewed, the manager failed to ensure a caregiver provided evidence of freedom from infectious tuberculosis (TB), as required by R9-10-113. The deficient practice posed a potential health and safety risk of TB exposure to residents and staff. Findings include: 1. In record review, the personnel records for E3 (hired as an assistant caregiver on December 18, 2023), did not include documentation the caregiver provided evidence of freedom from TB, as required. 2. In documentation review, the staffing schedule for March 2024, included documentation the assistant caregiver worked shifts at the facility. 3. During an interview, E1 acknowledged the personnel record for the assistant caregiver did not include documentation that E3 provided evidence of freedom from TB, as required by R9-10-113.

Based on record review and interview, the manager failed to ensure a resident had a written service plan to include the amount, type, and frequency of assisted living services being provided to the resident, for one of two residents sampled. Findings include: 1. A review of R2's medical record revealed an initial service plan for personal care services dated February 13, 2023. The service plan contained a section titled "ADL's - Review level of care for activities of daily living," beneath which the following services were listed: "Bathing", "Dressing", "Eating", "Oral Care", "Toileting", and "Mobility & Transferring." Below each listed service was a section to indicate what level of assistance was required for each service. However, the section beneath each service was blank, and the service plan did not indicate the amount, type, and frequency of assisted living services to be provided to R2. 2. In an interview, E2 reported the facility provided R2 assistance with all of the activities of daily living (ADLs) listed on R2's initial service plan. E2 acknowledged R2's service plan did not include the amount, type, and frequency of assisted living services to be provided to R2.

Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver documented the services provided to a resident in the resident's medical record, for one of two residents sampled. Findings include: 1. A review of R2's medical record revealed a service plan dated July 11, 2023 for personal care services. The service plan listed the following services to be provided for R1: -"Dressing - Full Assistance...Daily @ wakeup and bedtime"; -"Oral Care - Full Assistance...Daily @ wakeup and bedtime"; and -"Mobility & Walking...Daily @ wakeup and bedtime." 2. A review of R2's electronic medical record revealed documentation of assistance with activities of daily living (ADLs) provided to R2 in August 2023. R1's August ADL log revealed assistance with "Oral Care", "Dressing", and "Mobility & Walking" were documented as provided in the mornings of August 19, 21, 22, 26, and 27, 2023. However, no documentation indicating the aforementioned services were provided at bedtime on the aforementioned dates was available for review. 3. In an interview, E1 reported the aforementioned services were provided to R2 according to the frequency specified in R2's service plan every day in August 2023. E1 acknowledged the services provided to R2 in the evening were not documented in R2's medical record.

Based on observation and interview, the manager failed to ensure oxygen containers were secured in an upright position. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed two unsecured oxygen tanks stored upright in the closet of R3's room, four unsecured oxygen tanks stored upright in R4's bedroom closets, and one unsecured oxygen tank stored upright in R5's bedroom closet. 2. In an interview, E2 acknowledged there were unsecured oxygen containers in R3's, R4's, and R5's bedroom closets. E2 reported E2 had ordered six stands for securing oxygen tanks while the Compliance Officer was on site.