Elegant Care II

Based on record review and interview, the health care institution 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 three personnel sampled. The deficient practice posed a health and safety risk for residents. Findings include: 1. A review of E1’s personnel record revealed documentation of completed fall prevention and fall recovery training conducted on February 1, 2024. However, E1’s personnel record did not include documentation of additional training on fall prevention and fall recovery. 2. In an interview, E1 reported the facility required all staff to complete continued competency training annually. 3. In an interview, E2 reported the facility required all staff to complete training on an annual basis. E2 acknowledged that the facility failed to administer a training program regarding fall prevention and fall recovery, for all staff, that included continued competency training. This is a repeat deficiency from the compliance inspection conducted on October 25, 2022.

Based on documentation review, observation, and interview, the manager failed to ensure that a list of resident rights was conspicuously posted. Findings include: 1. R9-101.54 states, "Conspicuously posted" means placed: a. At a location that is visible and accessible; and b. Unless otherwise specified in the rules, within the area where the public enters the premises of a health care institution." 2. During the environmental tour of the facility, the Compliance Officers observed the facility's required postings located in frames in the facility's entryway. However, a list of resident rights was not conspicuously posted. 3. In an interview, E1 reported the facility had a resident rights posting, and obtained the required posting while the Compliance Officers were on-site. However, E1 acknowledged that a list of resident rights was not conspicuously posted at the time of inspection.

Based on observation, record review, and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided health services for two of three personnel sampled. The deficient practice posed a risk if a personnel member was unable to meet a resident's needs. Findings include: 1. While on-site for the compliance inspection, the Compliance Officers observed E1 and E2 at the facility, providing services to residents. 2. A review of E1's and E2's personnel records revealed documentation of a form titled "New Orientation Checklist." However, the form did not include documentation of the verification of E1's and E2's skills and knowledge. 3. In an interview, E1 acknowledged E1's and E2's skills and knowledge were not verified and documented before E1 and E2 began providing health services at the facility. Technical assistance was provided regarding this rule during the compliance inspection conducted on October 25, 2022.

Based on documentation review, record review, and interview, the manager failed to ensure that a personnel record for each employee included documentation of the individual's completed orientation required by policies and procedures, for one of three personnel sampled. The deficient practice posed a risk as the caregiver received no organized instruction or information related to physical health services provided to residents. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "Employee New Orientation." The policy stated, "1. Employee orientation-Before providing assisted living services to a resident, a manager, caregiver, or an assistant caregiver receives orientation that is specific to the duties to be performed by the manager, caregiver, or assistant caregiver." 2. A review of E3's personnel record revealed no documentation of a completed employee orientation. 3. In an interview, E1 acknowledged E3's personnel record did not contain documentation of E3's completed orientation required by policies and procedures. Technical assistance was provided regarding this regulation during the compliance inspection conducted on October 25, 2022.

Based on record review and interview, the manager failed to ensure that before or at time of acceptance of an individual submitted documentation that was dated within 90 calendar days before the individual was accepted by an assisted living facility and included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints and was signed and dated by a medical practitioner, 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 a document titled "Physician's Pre-Admission Evaluation and Determination of Acceptance Into Facility." This document contained whether or not R1 required continuous medical services, continuous or intermittent nursing services, or restraints and was signed and dated by a registered nurse or medical practitioner. However, the form was not signed before R1’s date of admission to the facility. 2. In an interview, E1 acknowledged R1's medical record did not contain the required documentation that was dated 90 days before R1 was accepted by the facility.

Based on observation and interview, the manager failed to ensure there was a means of exiting the facility that controls or alerts 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. During an environmental tour of the facility, the Compliance Officers observed the front door, sliding back door, patio door, shared resident bathroom door that leads to the back yard, and a garage door with no means of alerting staff of egress. 2. In an interview, E1 reported the facility's doors were equipped with 'jingle bells' to alert the caregivers of egress. However, the bells did not make noise when the Compliance Officers opened the doors.  3. In an interview, E1 acknowledged the facility provided directed care services and did not contain a way to control or alert employees of the egress of a resident from the facility on all exits.

Based on documentation review, observation, and interview, the manager failed to ensure that an evacuation path was conspicuously posted in each hallway of the assisted living facility. The deficient practice posed a risk as there was no plan to ensure the health and safety of residents in an emergency. Findings include: 1. R9-101.54 states, "Conspicuously posted" means placed: a. At a location that is visible and accessible; and b. Unless otherwise specified in the rules, within the area where the public enters the premises of a health care institution." 2. During an environmental tour of the facility, the Compliance Officers observed an evacuation route posted in the hallway that leads to the facility’s garage. However, additional evacuation route postings were not available for review. 3. In an interview, E1 acknowledged the facility’s evacuation routes were not posted in each hallway of the facility.

Based on observation and interview, the manager failed to ensure the premises were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a risk to the physical health and safety of residents. Findings include: 1. During an environmental tour of the facility, Compliance Officers observed a staircase leading to a downstairs floor of the assisted living home. The top of the staircase was controlled with a gate and equipped with a lock. However, at the time of inspection, the gate and lock were not secured. 2. While on-site for the compliance inspection, the Compliance Officers observed residents who were able to ambulate independently. 3. In an interview, E2 acknowledged the premises and equipment used at the facility were not free from a condition or situation that may cause a resident or other individual to suffer physical injury. E2 reported the facility's bottom floor is used as a studio apartment and not accessible to residents.

Based on observation and interview, the manager failed to ensure that Oxygen containers were secured in an upright position. The deficient practice posed a potential explosion or leak of compressed gas. Findings include: 1. During an environmental tour of the facility, the Compliance Officers observed three oxygen canisters stored upright in the corner of R1’s bedroom. However, the canisters were not secured in any way. 2. In an interview, E2 reported the canisters should have been stored in a designated container for oxygen storage. E1 acknowledged that oxygen canisters stored by the facility were not secured in an upright position.