Embrace Hope LLC - E Shiloh Place

Based on documentation review and interview, the administrator failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if personnel members were unable to implement a disaster drill. Findings include: 1. A review of facility documentation revealed resident evacuation drills and employee evacuation drills. However, documentation of employee disaster drills was not available for review. 2. In an exit interview with E1, E2, and E3, the findings were reviewed an no additional information was provided.

Based on record review and interview, the chief administrative officer failed to ensure, for one of three sampled employees, baseline screening was documented to include assessing risks of prior exposure to infectious tuberculosis, determining if the individual has signs or symptoms of tuberculosis, and obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1). Findings include: 1. A review of E4's personnel record revealed E4 was hired as a direct care worker in May of 2024. 2. A review of E4's personnel record revealed a single step tuberculosis skin test (TST) which was read three days after E4's date of hire. However, a second step TST was not available for review. 3. A review of E4's personnel record revealed a "TB Screening Questionnaire" dated more than a year after E4's date of hire. However, baseline screening conducted at the time E4 had been hired was not available for review. 4. In an exit interview with E1, E2, and E3, the findings were reviewed and no additional information was provided.

Based on documentation review and interview, the administrator failed to designate, in writing, individuals who would be present on the premises of the nursing-supported group home and accountable for the nursing-supported group home when the administrator was not present on the nursing-supported group home's premises. Findings include: 1. A documentation review of the facility's written designation of individuals who would be present and accountable for the facility when the administrator was not present revealed a designation was not available for review. 2. In an exit interview with E1, E2, and E3, the findings were reviewed and no additional information was provided.

Based on documentation review, record review, and interview, the administrator failed to establish, document, and implement policies and procedures to protect the health and safety of a resident which covered cardiopulmonary resuscitation training, including the method and content of cardiopulmonary resuscitation training, to include a demonstration of the ability to perform cardiopulmonary resuscitation, for one of three sampled personnel. The deficient practice posed a risk if the employee was unable to meet a resident's needs during an emergency. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Pre-Service Orientation/Training Plan," issues March 20, 2020. This policy stated, "G: When member is present in the site and is not utilizing ISP authorized alone time, employees providing services will have completed the following minimum required training:...2. Cardiopulmonary resuscitation (CPR), provided by a certified instructor." However, the policy did not require the CPR training to include a demonstration of the ability to perform CPR, the time frame for renewal of CPR training, or the documentation that verifies an individual has received CPR training. 2. A review of E4's personnel record revealed E4 was hired as a "DCW" in May of 2024. 3. A review of E4's personnel record revealed a job description for the job titled, "DSP - Direct Care Staff," revised February 17, 2025. The job description included the following requirement: "Ensuring that you maintain compliance in CPR & 1st Aid." 4. A review of E4's personnel record revealed a copy of a CPR and First Aid training certificate, dated June 8, 2024, issued by "NationalCPRFoundation," an online only provider whose CPR training programs do not include a demonstration of the ability to perform CPR. 5. During the on-site inspection, E2 contacted E4, who stated the certificate was from an in-person CPR class E4 had attended while working for a different employer. 6. In an exit interview with E1, E2, and E3, the findings were reviewed and no additional information was provided.

Based on record review and interview, the administrator failed to ensure a resident's medical record contained all required documentation, for one of one sampled resident. Findings include: 1. A review of R1's medical record revealed a placement evaluation dated a year after R1's date of admission. However, documentation of a placement evaluation dated on or before R1's date of admission was not available for review. 2. A review of R1's medical record revealed R1 was a minor. R1's medical record documented R1 had a guardian, however a copy of the court order establishing guardianship was not available for review. 3. A review of R1's medical record revealed a medical and history examination dated more than one year after R1's date of admission. However, documentation of a medical history and physical examination dated within 30 calendar days prior to admission or up to 10 working days after admission was not available for review. 4. A review of R1's medical record revealed a comprehensive assessment. However, the assessment did not include all required information per R9-10-2214.A. 5. A review of R1's medical record revealed a nursing care plan, dated March 7, 2025. However, the nursing care plan did not include all required information per R9-10-2214.B and was dated more then 37 days after R1's date of admission. 6. A review of R1's medical record revealed documentation of physical health services provided to R1 were not available for review. 7. In an exit interview with E1, E2, and E3, the findings were reviewed and no additional information was provided.

Based on documentation review, record review and interview, the administrator failed to ensure a pharmacist reviewed a resident's medications at least once every three months and provided documentation to the resident's designated medical practitioner and the director of nursing indicating potential medication problems such as incompatible or duplicative medications, for one of one sampled resident. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Medication Services / Pharmacy Services," dated December 7, 2022. This policy stated, "Pharmacy Reviews must be conducted once every 3 months, for each resident, by a licensed pharmacist. During the review, the pharmacist will review the resident's medical chart, history, and both prescription and over-the-counter medications. Any irregularities noted by the pharmacist during the Pharmacy Review must be documented in a separate, written report that is sent to the resident's designated medical practitioner and the director of nursing. This document at minimum will include the date of the review, pharmacist name and NPI number, resident's name, the relevant drug, and the irregularity identified by pharmacist." 2. A review of R1's medical record revealed documentation of pharmacy reviews were not available for review. Based on R1's date of admission, multiple pharmacy reviews were required. 3. In an exit interview with E1, E2, and E3, the findings were reviewed and no additional information was required.

Based on observation, documentation review and interview, the administrator failed to ensure fire extinguishers were inaccessible to residents, smoke detectors were installed in each bedroom, and smoke detectors were tested each month, with documentation of the test maintained for at least 12 months. Findings include: 1. During a facility tour, the Compliance Officer observed wall mounted fire extinguishers in the kitchen and living room. However, both fire extinguishers were accessible to residents. 2. During a facility tour, the Compliance Officer observed the bedroom marked, "Bedroom #2" on the facility floor plan did not have a smoke detector. 3. A documentation review of the facility's monthly smoke detector tests revealed documentation of monthly smoke detector testing was not available for review. 4. In an exit interview with E1, E2, and E3, the findings were reviewed and no additional information was provided.