Angel Care Home

Based on observation, documentation review, and interview, the manager failed to ensure a designated caregiver was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present on the assisted living facility premises. The deficient practice posed a risk as no individual was designated to act on behalf of the governing authority in the onsite management of the assisted living facility. Findings include: 1) During the arrival of the Compliance Officers at the facility at 9:35 AM, it was observed that there was no manager nor manager designee present onsite. A caregiver called E2 to come to the facility. 2) During the environmental inspection, a posted document was observed that listed E1 as the manager and E2 as the designated manager. The document was signed by E1 and dated November 12, 2024. 3) In an interview, E2 revealed that E1 had a second job and that E2 was just down the street and could come over to the facility if needed. E2 acknowledged that there was no designated acting manager onsite.

Based on observation and interview, the manager failed to ensure there was a means of exiting the facility to control or alert 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. Finding include: 1. The Compliance Officer observed two doors at the front of the house without an alert. 2. The Compliance Officer observed a door leading to the backyard with an alert. However, the alert was not operational. 3. The Compliance Officer observed a door at the end of the hall leading to the backyard without an alert. 4. In an interview, E1 and E2 reported not having knowledge of a requirement for a means of exiting the facility to control or alert employees of the egress of a resident from the facility. 5. In an interview, E2 acknowledged E2 failed to ensure there was a means of exiting the facility to control or alert employees of the egress of a resident from the facility.

Based on documentation review, record review and interview, the manager failed to ensure a personnel record for each employee included documentation of cardiopulmonary resuscitation training (CPR) and first aid training, for one of four employees sampled. The deficient practice posed a risk if E3 was unable to meet a resident's needs during an emergency, accident or injury. Findings include: R9-10-806.A.10. A manager shall ensure that: Before providing assisted living services to a resident, a manager or caregiver provides current documentation of first aid training and cardiopulmonary resuscitation training certification specific to adults. 1. A review of facility documentation revealed a undated policy and procedure titled "CPR and First Aid." The policy and procedure stated "Per department of health all staff must obtain and provide documentation of first aid training and cardiopulmonary resuscitation training (CPR) specific to adults." 2. A review of E3's (hired in June 2023) personnel record revealed documentation of cardiopulmonary resuscitation training (CPR) and first aid training was not available for review. 3. In an interview, E2 reported E3 had taken CPR and first aid training but had yet to received the training card. 4. In an interview, E2 acknowledged E2 failed to ensure a personnel record for each employee included documentation of CPR and first aid training.