Big Heart Angels Care Home LLC

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 for one of two personnel sampled. The deficient practice posted a health and safety risk for residents. Findings include: 1. A review of the facility's policies and procedures (reviewed July 10, 2024) revealed an addendum titled, "Fall Prevention and Recovery." The policy stated, "A manager shall develop and administer a training program for all staff regarding Fall Prevention and Fall Recovery. The training program shall include initial training and continued competency training in Fall Prevention and Fall Recovery." 2. A review of E2's personnel record revealed no documentation of Fall Prevention and Fall Recovery training. 3. In an interview, E2 acknowledged documentation of Fall Prevention and Fall Recovery training was not maintained in compliance with the facility's policies and procedures in E2's personnel record. This is a repeat citation from the compliance inspection conducted on September 30, 2022.

Based on documentation review and interview, the manager failed to ensure that as part of the policies and procedures required in R9-10-803(C)(1)(h), a plan was implemented to ensure that the manager or a caregiver was available as back-up to provide assisted living services to a resident if the caregiver assigned to work was not available or not able 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 policies and procedures revealed a policy titled, "Back-up Staffing." The policy stated, "The Manager shall ensure: a Manager and a Caregiver are available as a backup to provide assisted living services to a resident if the manager or a caregiver assigned to work is unavailable or unable to provide the required assisted living services." 2. A review of the facility's employee schedule revealed E2 was on shift from 6:00AM - 6:00PM and 6:00PM - 6:00AM daily over the course of the previous 10 months. No further documentation of additional available staff was available for Compliance Officer review. 3. In an interview, E2 acknowledged there was not a plan implemented to ensure that the manager or a caregiver was available as back-up to provide assisted living services to a resident if the caregiver assigned to work was not available or not able to provide the required assisted living services. When asked what the protocol would be if E2 was not available or not able to provide assisted living services, E2 stated, "They would have to find somebody." This is a repeat deficiency from the compliance inspection conducted on September 30, 2022.

Based on record review and interview, the manager failed to ensure that a caregiver accurately documented the services provided in the resident's medical record. The deficient practice posed a risk as the documentation did not accurately reflect the services provided. Findings include: 1. A review of R1's current service plan, dated May 3, 2024, revealed R1 was expected to shower, perform daily grooming, perform skin maintenance, dress, and toilet independently. 2. A review of R1's activities of daily living (ADL) documentation for the month of July 2024 revealed E2 provided the following assisted living services to R1 daily: - Assistance with showering; - Hair grooming; - Oral care; - Skin care; - Finger nail care; - Assistance in dressing; and - Assistance in toileting. 3. In an interview, E2 reported R1 had performed the above mentioned activities of daily living independently. E2 acknowledged R1's medical record did not accurately document the services provided. Technical assistance was provided regarding this rule during the on-site compliance inspection conducted on September 30, 2022.

Based on observation, record review, and interview, the manager failed to ensure that a bell or other mechanical means to alert employees to a resident's needs or emergencies was available in a bedroom being used by a resident receiving personal care services. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental tour of the facility, the Compliance Officers observed that R1's and R2's shared room contained bells as a means to alert employees of a need or emergency. Both bells were placed on the floor, under an end table, and inaccessible to the residents in an emergency scenario. 2. A review of R1's and R2's medical records revealed R1 and R2 received personal care services. 3. In an interview, E2 reported R1 moved the bells from their normal location. E2 acknowledged R1 and R2 did not have a means to alert employees to their needs or emergencies. Technical assistance was provided regarding this rule during the on-site compliance inspection conducted on September 30, 2022.

Based on documentation review, observation, and interview, the manager failed to ensure that a smoke detector was tested once a month. The deficient practice posed a health and safety risk to the residents. Findings include: 1. A review of the facility's monthly maintenance record revealed a test of the smoke detectors documented on May 28, 2023. No other documentation of monthly tests were available for Compliance Officer review. 2. During an environmental tour of the facility, the Compliance Officers observed a smoke detector located in the entryway of the facility that was beyond reach of the caregiver with the use of a ladder. 3. In an interview, E2 reported not testing the smoke detector observed due to inability to reach. E2 acknowledged the smoke detectors were not tested at least once a month. This is a repeat citation from the compliance inspection conducted on September 30, 2022.