Sun Valley Heights Assisted Living

Based on documentation review, 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 to the outside area allowing the resident to be at least 30 feet away from the facility. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. The Compliance Officer observed one ambulatory resident on the premises. 3. During the environmental inspection of the facility, the Compliance Officer observed a door leading out to the back yard area, which allowed residents to be at least 30 feet away from the facility. The door was lockable from the inside. However, the door was not controlled and did not alert employees of the egress of a resident from the facility to the outside area. 4. During the environmental inspection of the facility, the Compliance Officer observed a sliding door in R3's bedroom leading out to the back yard area, which allowed residents to be at least 30 feet away from the facility. However, the door was not controlled and did not alert employees of the egress of a resident from the facility to the outside area. 5. In an interview, E1 acknowledged the doors leading to the outside area did not control or alert employees of the egress of a resident from the facility.

Based on documentation review, record review, and interview, the health care institution failed to 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. Findings include: 1. A review of the facility's policies and procedures revealed an undated policy titled "POLICY TOPIC: FALL PREVENTION AND RECOVERY TRAINING". The policy stated "The facility, as a licensed healthcare institution, has developed and administers a training program for all caregiving staff regarding fall prevention and fall recovery. The training program requires initial training and continued competency review on an annual basis in fall prevention and fall recovery." 2. A review of E2's personnel record revealed documentation of initial training or continued competency training in fall prevention and fall recovery was not available for review. 3. In an interview, E1 reported E2 did not complete fall prevention and fall recovery training. E1 acknowledged fall prevention and fall recovery was not administered to all staff. This is a repeat citation from the previous on-site compliance inspection conducted on September 14, 2022.

Based on documentation review and interview, the manager failed to ensure policies and procedures were reviewed at least once every three years. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "POLICY TOPIC: R9-10-803.C.3:-POLICY AND PROCEDURE ANNUAL REVIEW SIGN OFF." The policy stated "I, [E1] the undersigned, acknowledge that I have reviewed these Policies and Procedures Manual in it's entirety." [sic] Below the subheading was a signature line. The signature line included E1's signature, and was dated January 28, 2019. 2. In an interview, E1 acknowledged the policies and procedures were not reviewed at least once every three years.