Faubush Family Homes.

“Based on record review and interview, the health care institution 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 for one of three personnel sampled. The deficient practice posed a health and safety risk for residents.  Findings include:  1. A review of E3’s personnel record revealed completed training regarding fall prevention completed on June 1, 2025. However, completed training regarding fall recovery was not available for review.  2. In an interview, E1 acknowledged the facility failed to develop and administer a training program for all staff regarding fall prevention and fall recovery that included initial and continued competency training.  This is a repeat deficiency from the compliance and complaint investigation conducted on July 17, 2023.”

“Based on documentation review, observation, record review, and interview, the manager failed to ensure that a caregiver provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of two personnel sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. R9-10-113.A states, "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of the Centers for Disease Control and Prevention website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST (Mantoux Skin Test) is used for baseline testing, two-step testing is recommended for HCWs (Health Care Workers) whose initial TST results are negative. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read." 3. While on-site for the compliance and complaint inspection, the Compliance Officer observed E3 at the facility, providing services to residents.  4. A review of E3's personnel record revealed a negative TB blood test that was less than 12 months old; however, no documentation of E3's risks of prior exposure to infectious tuberculosis and if E3 had signs or symptoms of tuberculosis was available. Based on E3’s date of hire, this documentation was required. 5. In an interview, E1 acknowledged E3 did not provide evidence of freedom from infectious TB as specified in R9-10-113. This is a repeat deficiency from the compliance and complaint investigation conducted on July 17, 2023.”

“Based on record review and interview, the manager failed to ensure that a resident had a written service plan that, when initially developed, was signed and dated by the resident or resident's representative, the manager, and the nurse who reviewed the service plan, for one of two residents sampled. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include:  1. A review of R2's medical record revealed a completed service plan dated May 20, 2025. However, the service plan was not signed and dated by the approving nurse, resident or resident's representative, and the manager.  2. In an interview, E1 acknowledged R2's service plan was not signed and dated by the resident or the resident's representative, the manager, and the nurse who reviewed the service plan.  3. This is a repeat deficiency from the compliance and complaint inspection conducted on July 17, 2023.”

“Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for two 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 R1's medical record revealed a service plan that indicated R1 would receive the following services: Maximum assistance with nutrition; Maximum assistance with hygiene; Two showers provided per week; Maximum assistance with hair washing and nail care, weekly; Maximum assistance with oral hygiene, twice a day (bid); Maximum assistance with dressing; Maximum assistance with walking and transferring; Maximum assistance with toileting; and Maximum assistance with skin care. 2. A review of R1's activities of daily living (ADL) documentation revealed missing documentation of all aforementioned services on the following dates: June 1-3, 2025, on the 6:00 AM - 2:00 PM shift; June 10, 2025, on the 2:00 PM - 10:00 PM shift; June 16- 17, 2025, on the 2:00 PM - 10:00 PM shift; June 16, 2025, on the 10:00 PM - 6:00 AM shift; June 19, 2025, on the 6:00 AM - 2:00 PM shift; June 23, 2025, on the 6:00 AM - 2:00 PM and 10:00 PM - 6:00 AM shifts; June 25 - 26, 2025, on the 2:00 PM - 10:00 PM shift; June 26, 2025 - present, on the 6:00 AM - 2:00 PM shift; and June 29, 2025 - present, on the 10:00 PM - 6:00 AM shift. 3. A review of R2's medical record revealed a service plan that indicated R2 would receive the following services:  Maximum assistance with nutrition; Maximum assistance with hygiene; Two showers provided per week; Maximum assistance with hair washing and nail care, weekly; Minimum assistance with oral hygiene, bid; Moderate assistance with dressing; Minimum assistance with walking and transferring; Maximum assistance with toileting; and Minimum assistance with skin care. 4. A review of R2's ADL documentation revealed missing documentation of all aforementioned services on the following dates: June 1-3, 2025, on the 6:00 AM - 2:00 PM shift; June 10, 2025, on the 2:00 PM - 10:00 PM shift; June 16- 17, 2025, on the 2:00 PM - 10:00 PM shift; June 16, 2025, on the 10:00 PM - 6:00 AM shift;  June 19, 2025, on the 6:00 AM - 2:00 PM shift; June 23, 2025, on the 6:00 AM - 2:00 PM and 10:00 PM - 6:00 AM shifts;  June 25 - 26, 2025, on the 2:00 PM - 10:00 PM shift;  June 26, 2025 - present, on the 6:00 AM - 2:00 PM shift; and  June 29, 2025 - present, on the 10:00 PM - 6:00 AM shift.  5. In an interview, E1 reported R1 and R2 received all services per R1’s and R2's service plan. E1 acknowledged a caregiver failed to document the services provided in R1's and R2's medical record.”

“Based on documentation review, observation, and interview, the manager failed to ensure that there was a means of exiting the facility that controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include:  1. A review of Department documentation revealed the facility was licensed to provide directed care services. 2. During an environmental tour of the facility, the Compliance Officer observed the back door from the facility equipped with an alarm to alert employees of egress; however, the alarms were not functioning at the time of inspection.  3. In an interview, E1 acknowledged that the facility provided directed care services, and did not contain a way to control or alert employees of the egress of a resident from the facility on all exits.”

“Based on record review, observation, and interview, the manager failed to ensure that a medication administered to a resident was administered in compliance with a medication order and documented in the resident's medical record, for one of two residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R2's medical record revealed medication orders for the following medications: Metoprolol Succinate 50 milligrams (mg), 1 tablet by mouth (po) once a day (qd); Carbidopa-Levodopa 25-100 mg, 1 tablet po four times a day;  Levothyroxine 125 micrograms (mcg), 1 tablet po qd;  Hydrocodone-Acetaminophen 10-325 mg, 1 tablet po twice a day (bid); and Flecainide Acetate 50 mg, 1 tablet po bid. 2. A review of R2's Medication Administration Record (MAR) for June 2025 revealed R2 was administered the following medications: Metoprolol Succinate 100 mg, 1 tablet po qd, and indicated 1 tablet was administered June 1, 2025 - present; Carbidopa-Levodopa 25-100 mg, 1 tablet at 8:00 AM, 8:00 AM [sic], and 12:00 PM, and indicated 1 tablet was administered June 1, 2025 - present; Levothyroxine 150 mcg, 1 tablet po qd, and indicated 1 tablet was administered June 1, 2025 - present; Hydrocodone-Acetaminophen 10-325 mg, 1 tablet po qd, and indicated 1 tablet was administered June 1, 2025 - present; and Flecainide Acetate 50 mg, 1 tablet po qd, and indicated 1 tablet was administered June 1, 2025 - present. 3. While on-site for the compliance and complaint inspection, the Compliance Officer observed the following medications available for administration to R2: Metoprolol Succinate 100 mg; Carbidopa-Levodopa 25-100 mg; Levothyroxine 150 mcg; Hydrocodone-Acetaminophen 10-325 mg; and Flecainide Acetate 50 mg. 4. The Compliance Officer also observed a medication organizer prefilled for R2, which indicated R2 received the following medications: Metoprolol Succinate 100 mg, 1/2 tablet po qd; Carbidopa-Levodopa 25-100 mg, 1 tablet po at 8:00 AM, 12:00 PM, and 4:00 PM; Levothyroxine 150 mcg, 1 tablet po qd; Hydrocodone-Acetaminophen 10-325 mg, 1 tablet po qd; and Flecainide Acetate 50 mg, 1 tablet po qd. 5. In an interview, E1 reported documentation on R2's MAR was not accurate, and would be adjusted for July 2025. E1 acknowledged medication was not administered to R2 in compliance with the aforementioned medication orders and documented in R2's medical record.”

“Based on observation, record review, and interview, the manager failed to ensure that medication stored by the facility was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to residents who were unable to self-administer medications. Findings include: 1. While on-site for the compliance and complaint inspection, the Compliance Officer observed a closet used for medication storage equipped with a locking mechanism. However, the medication closet was not locked at the time of inspection. 2. In an interview, E1 acknowledged medication stored by the facility was not stored in a separate locked room, closet, cabinet or self-contained unit used only for medication storage.”

“Based on observation and interview, the manager failed to ensure that oxygen containers were secured in an upright position. The deficient practice posted a potential explosion or leak of compressed gas.  Findings include:  1. During an environmental tour of the facility, the Compliance Officer observed an oxygen container stored upright in the entryway of the home. However, the container was not secured in any way.  2. In an interview, E1 reported that the containers should have been stored in a designated container for oxygen storage. E1 acknowledged that the oxygen container stored by the facility was not secured in an upright position.”