LA SIENA

Based on documentation review, record review, and interview, the manager failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training. The deficient practice posed a risk to the physical health and safety of a resident.

Findings include:

1. A review of E1's personnel record revealed training in fall prevention and fall recovery was not available for review for the years 2023 and 2024. However the initial training was completed in June 2018.

2. A review of E2's personnel record revealed continued competency training in fall prevention and fall recovery. However there was no date to verify when the continued competency training in fall prevention and fall recovery took place.

3. In an interview, E1 acknowledged E1 did not have fall training and fall recovery training available for review at the time of the inspection for 2023 and 2024. E1 acknowledged E2 had continued competency training in fall prevention and fall recovery but there was no date to verify when the training took place.

Based on record review and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before providing physical health services and according to policies and procedures, for one of two caregivers sampled. The deficient practice posed a health and safety risk.

Findings include:

1. A review of E2's personnel record revealed a job description, which included but not limited to:
- "Customizing Supportive services that are tailored to the specific needs and preferences of residents and their families"
- "Delivering services and monitoring resident needs according to the resident's service plan including; personal care, monitoring health needs and assisting residents with medications (as delegated by the LPN) per state regulations"

2. A review of E2's personnel record revealed a document titled, "Caregiver Orientation training Verification (AZ)" which had a section titled, "Caregiver Orientation Training." This section had the following courses that were presented to the Compliance Officer as the skills and knowledge verification:
- Introduction;
- SRG Policies and Forms;
- Resident Rights;
- Cultural Competency; and
- Emergency preparedness.
However these courses do not list the specific skills and knowledge necessary for the caregiver or assistant caregiver to provide the expected assisted living services as mentioned in the job description.

3. In an interview, E1 acknowledged the orientation training do not list the specific skills and knowledge necessary for the caregiver to provide the expected assisted living services as mentioned in the job description

Based on record review and interview, the manager failed to ensure when a resident had an incident resulting in the resident needing medical services, a caregiver documented any action taken to prevent the incident from occurring in the future, for one of two residents reviewed who had an incident resulting in the resident needing medical services. The deficient practice posed a health and safety risk.

Findings include:

1. A review of R2's medical record revealed incident reports dated in August 2024 and October 2024 that indicated medical services were required. The documentation did not include any action taken to prevent the incident from occurring in the future.

2. In an interview, E1 acknowledged R2 had incidents resulting in needing medical services and R2's medical record did not include documentation of any action taken to prevent the incidents from occurring in the future.