Archangel Assisted Living II

Based on 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 continued competency training. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. Review of E1's personnel record revealed a certificate for Fall Prevention and Fall Recovery training dated September 12, 2022. However, the personnel record did not include current documentation of fall prevention and fall recovery training. 2. In an interview, E3 acknowledged E1's personnel record did not contain documentation that showed E1 completed continued competency training regarding fall prevention and fall recovery.

Based on documentation review, observation, and interview, the manager failed to ensure there was a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort, that provided access to an outside area, and 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. Review of Department documentation revealed the facility was authorized to provide directed care services. 2. Review of facility policies and procedures revealed a document titled "Wandering," which stated: "If alarms are being used on doors and/or windows, the caregiver will check them daily for operation and security." 3. During the facility tour with E1, the Compliance Officer observed the door leading out to the backyard. The outside area, in the backyard, allowed residents to be at least 30 feet away from the facility. The door leading out to the backyard had a device that was intended to alert employees to the egress of a resident to the outside area. However, the device did not work. 4. In an interview, E3 reported the alarm did work, but it was turned off. E3 acknowledged there was not a means of exiting the facility that controlled or alerted employee of the egress of the resident.

Based on observation, documentation review, and interview, the manager failed to ensure a current drug reference guide was available for use by personnel members. Findings include: 1. The Compliance Officer observed the facility's drug reference guide was the "Mosby's 2021 Nursing Drug Reference, 34th Edition". 2. Review of the publisher's website revealed the "Mosby's 2024 Nursing Drug Reference, 37th Edition" was the most recent edition. 3. In an interview, E3 acknowledged that a current drug reference guide was not available for use by personnel members.

Based on observation and interview, the manager failed to ensure that a current toxicology reference guide was available for use by personnel members. Findings include: 1. The toxicology guide available for use by personnel members was the "Casarett & Doull's Essentials of Toxicology, Second Edition" published in 2010. 2. Review of the website for the toxicology guide revealed the "Casarett & Doull's Essentials of Toxicology, Fourth Edition" was the most recent edition. 3. In an interview, E3 acknowledged that a current toxicology reference guide was not available for use by personnel members.