Ccc B&b LLC Carehome

Based on documentation review, record review, and interview, the administrator failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery, including initial training and continued competency training. The deficient practice posed a risk if facility staff were not properly trained to assist a resident who had fallen and was unable to recover independently. Findings include: 1. A review of facility documentation revealed a documented fall prevention and fall recovery training program. However, the fall prevention and fall recovery training program did not include initial training and continued competency training. 2. A review E4's and E5's personnel records revealed no documented evidence to indicate E4 and E5 completed fall prevention and fall recovery training. 3. In an interview, E1 acknowledged the facility's fall prevention and fall recovery training program failed to address initial and continued compentency training, and there was no documentation to indicate E4 and E5 completed fall prevention and fall recovery training.

Based on documentation review, record review, and interview, the manager failed to ensure a manager or caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification specific to adults before providing assisted living services to a resident, for one of five sampled caregivers. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. A review of facility work schedules dated November 27, 2023 through December 3, 2023, reflected E3 was scheduled to work the following times and dates: -Monday, November 27, 2023 from 6:30 AM to 5:00 PM; -Tuesday, November 28, 2023 from 1:30 PM to 3:00 PM; -Wednesday, November 29, 2023 from 8:45 AM to 5:00 PM; and -Thursday, November 3, 2023 from 8:00 AM to 5:00 PM. 2. A review of E3's personnel record revealed no documentation of CPR or first aid training. 3. In an interview, E1 acknowledged E3's personnel record did not include documentation of current CPR and first aid training.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted by the facility, to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant, for one of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R1's medical record revealed an undated document titled "Pre Admission Determination". The document reflected R1 did not require continuous medical services, continuous or intermittent nursing services, or restraints. However, the document was not signed or dated by a physician, registered nurse practitioner, registered nurse, or physician assistant. 2. In an interview, E1 acknowledged R1's "Pre-Admission Determination" was not signed or dated by a physician, registered nurse practitioner, registered nurse, or physician assistant. This is a repeat citation from the previous compliance inspection conducted on September 26, 2022.

Based on record review and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan, for one of two residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R2's medical record a service plan dated October 25, 2023. R2's service plan reflected R2 required assistance with bathing twice weekly, skin care twice weekly, night checks every one to two hours, and "occasional" peri-care. 2. A review of R2's medical record revealed an activities of daily living (ADL) sheet dated November 2023. The ADL sheet did not reflect R2 was provided assistance with skin care twice weekly, "occasional" peri-care, or night checks every one to two hours as stated in R2's service plan. 3. In an interview, E1 reported R2 received the services according to R2's service plan, however the services were not documented.