Angels Assisted Living Home LLC

Based on record review and interview, the manager failed to ensure that a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services for one of one caregiver sampled. The deficient practice posed a risk if a personnel member was unable to meet a resident's needs. Findings include: 1. A review of E1's personnel record did not include documentation of E1's skills and knowledge. 2. In an interview, E1 reported E1 was the sole care staff member of the facility and provided physical health services. E1 acknowledged verification of E1's skills and knowledge was not documented before E1 provided physical health services.

Based on documentation review and interview, the manager failed to ensure that a plan was established, documented, and implemented to ensure the manager or a caregiver was available as back-up to provide assisted living services to a resident if the manager or a caregiver assigned to work was not available to provide the required assisted living services. The deficient practice posed a risk to the health and safety of the residents. Findings include: 1. A review of the facility's personnel schedule for December 2024, revealed E1 was scheduled to work 24 hours a day, seven days a week for the entire month. 2. In an interview, E1 reported E1 was the only care staff employed by the facility, and there was no plan established if E1 was unable to provide the required assisted living services. E1 acknowledged that a plan was not established, documented, or implemented to ensure the manager or a caregiver was available as back-up to provided assisted living services to a resident if E1 was not able to provide the required assisted living services.

Based on record review, observation, 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. The deficient practice posed a risk as false or misleading documentation was provided to the department. Findings include: 1. A review of R1's medical record revealed a service plan, dated December 1, 2024, that indicated R1 would receive the following services: - Linen change/Bed making, daily; - Room cleanings, daily; - Night checks, nightly; - Offering of fluids, three times a day (tid); - Assistance with toileting; - Bladder care; and - Bowel care. 2. A review of R1's activities of daily living (ADL) documentation, for November 2024, did not include documentation of the aforementioned services provided on the following dates: - November 28, 2024; - Nonmember 29, 2024; and - November 30, 2024. 3. While on-site for the compliance inspection, the Compliance Officers observed E1 backdating R1's ADL documentation for November 2024. 4. In an interview, E1 reported R1 received all assisted living services required within the month of November 2024. E1 acknowledged a caregiver failed to document the services provided in R1's medical record.