Vista Living Camelback View

Based on the record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record for one of two residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings Include: 1. A review of R2's medical record revealed a service plan (dated March 5, 2025) that indicated R2 received directed care. 2. A review of R2's medical record did not include ADL documentation of the services provided to R2. 3. In an interview, E1 acknowledged that the services provided to R2 were not documented in R2's medical records.

Based on the record review and interview, the manager failed to ensure a written service plan included the signature and date from the resident or resident’s representative for one of two residents reviewed. The deficient practice posed a health and safety risk if the resident or representative did not acknowledge the services to be provided. Findings include: 1. A review of R2's medical record revealed the most recent written service plan for personal care services dated in March, 2025. However, this service plan did not include a signature and date from the resident or the resident’s representative. 2. In an interview, E1 acknowledged that R2’s service plan did not include a signature and date from the resident or the resident’s representative.

Based on the record review and interview, the manager failed to ensure that the healthcare institution administered a training program for all staff regarding fall prevention and fall recovery, which included both initial training and continued competency training for one of the three personnel sampled. The deficient practice posed a health and safety risk for residents. Findings include: 1. A review of E2’s personnel record revealed E2 was hired as a caregiver in October, 2023. 2. A review of E2's personnel record revealed documentation of Fall Prevention and Fall Recovery Training for 2024. However, no initial fall prevention and recovery training documentation was available for the Compliance Officer to review. 3. In an interview, E1 acknowledged that the facility failed to administer a training program for E2 regarding fall prevention and recovery that included initial training.