Gifts of Grace Assisted Living Homes

Based on observation, documentation review, and interview, the manager failed to ensure there were policies and procedures that cover methods by which the assisted living facility is aware of the general or specific whereabouts of a resident. Findings include: 1. The facility was licensed for Directed Care. 2. Compliance officers observed ambulatory residents. 3. A review of facility Policy and Procedures, July 2016, revealed that there was no policy to address the whereabouts of residents. 4. In an interview, E1 acknowledged that there were no policies and procedures that cover methods by which the assisted living facility is aware of the general or specific whereabouts of a resident.

Based on observation and interview, the manager failed to ensure that a bell, intercom, or other mechanical means to alert employees to a resident’s needs or emergencies is available in a bedroom being used by a resident receiving directed care services for three of nine residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1.The facility is licensed for Directed Care 2. During the environmental tour the Compliance Officers observed three of nine residents that did not have a means to alert employees of their needs or emergencies while in bed. 3. In an interview, E1 acknowledged that a bell, intercom, or other mechanical means to alert employees to a resident’s needs or emergencies is available in a bedroom being used by a resident receiving directed care services.

Based on observation and interview the manager failed to ensure there was a means of exiting the facility to control or alert employees of the egress of a resident from the facility for four of four doors. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. Facility is licensed for Directed Care 2. Compliance officers observed ambulatory residents within the facility. 3. Compliance officers observed the following: -The front entry door had an alarm that was turned off -R1 had a door in their bedroom that led to the outside and the alarm was turned off -R2 had a door in their bedroom that led to the outside and the alarm was turned off -A door leading to the backyard had the alarm turned off and the batteries were not functioning. 4. In an interview, E1 acknowledged that these exits did not alert employees of the egress of a resident from the facility.

Based on observation, documentation review, and interview, the manager failed to ensure that oxygen containers were secured. The deficient practice posed a potential explosion or leak of a compressed gas. Findings include: 1. During the facility inspection, the Compliance Officers observed oxygen tanks in the living room closet that were not secured. 2. A review of facility policy and procedure revealed a policy titled "Environmental Safety" which stated, "A manager shall ensure that oxygen containers are secured in an upright position". 3. In an interview, E1 acknowledged that there were Oxygen tanks stored and not secured.

Based on documentation review, record review, and interview, the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of facility documentation revealed no documented policy for fall prevention and fall recovery. 2. A review of E2's and E3's personnel records revealed no documentation of fall prevention and fall recovery training. 3. In an interview, E1 acknowledged E2's and E3's personnel records did not include documentation of fall prevention and fall recovery training. E1 indicated E2 and E3 completed the training and it was listed on their "ongoing training forms." E1 was unable to name the course trainer or provide a course curriculum or description to the Compliance Officer within the two-hour time limit required by the Department.

Based on interview, record review, and documentation review, the manager failed to ensure that a caregiver's or assistant caregiver's skills and knowledge were verified and documented before the caregiver or assistant caregiver provided physical health services. The deficient practice posed a risk to the health and safety of residents if the caregivers and assistant caregivers were unable to meet the needs of the residents. Findings include: 1. In an interview, R3 reported E4 frequently administered medication to R3 during the evening while E3 was on vacation. 2. A record review revealed no personnel record for E4. 3. A review of the facility's policies and procedures included a policy titled, "Staff Documentation and Record Keeping." The policy's copyright date was 2016; however, the facility's policies and procedures were most recently updated on July 1, 2023. The policy indicated a job applicant's references and fingerprint clearance card would be verified once the decision to hire the applicant was made. 4. In an interview, E1 reported the facility's procedure for verifying a caregiver's or assistant caregiver's skills and knowledge included contacting their references and verifying the fingerprint clearance card issued to them by the Department of Public Safety was valid. E1 reported E4's skills and knowledge were not verified and documented because E4 was not an employee or volunteer of the facility. E1 acknowledged E4 administered medications, transferred, and provided other physical health services to residents.

Based on interview, documentation review, and record review, the manager failed to ensure that the assisted living facility had a caregiver with the qualifications, experience, skills, and knowledge necessary to provide the assisted living services in the assisted living facility's scope of services. The deficient practice posed a risk to the health and safety of residents if the caregivers and assistant caregivers were unable to meet the needs of the residents. Findings include: 1. In an interview, R3 reported E4 frequently administered medication to R3 during the evening while E3 was on vacation. 2. A record review revealed no personnel record for E4. 3. A review of the facility's policies and procedures included a policy titled, "Scope of Practice of the Assisted Living Facility." The policy's copyright date was 2016; however, the facility's policies and procedures were most recently updated on July 1, 2023. The policy indicated the facility provided assistance in the self-administration of medication and medication administration services. 4. In an interview, E1 reported E4 was not an employee or volunteer for the facility, but rather a friend who was helping out while E3 was on vacation. E1 reported E4 completed housekeeping duties. E1 acknowledged E4 entered the residents rooms to complete some housekeeping duties. E1 acknowledged E4 administered medication to residents. E1 indicated E4 provided assisted living services to residents during the nighttime hours while the live-in caregiver slept. E1 acknowledged there was no personnel file with the qualifications, experience, skills, and knowledge necessary to provide the assisted living services in the facility's scope of services. E1 did not know E4's last name or if E4 had the qualifications necessary to provide the services E4 had provided to residents.

Based on interview and record review, the manager failed to ensure a personnel record was available for one of three sampled employees or volunteers. The deficient practice posed a risk as the Department was unable to verify the job duties of E4 and if E4 was safe to work with a vulnerable population. Findings include: 1. In an interview, R3 reported E4 sometimes administered medications to R3 at nighttime. 2. In an interview, R2 reported to have observed E4 cooking and cleaning in the facility. 3. In an interview, E1 acknowledged E4 administered medication to residents, cooked for the residents, and cleaned the facility. E1 did not know E4's last name. 4. A record review revealed no personnel record for E4.

Based on record review and interview, the manager failed to ensure a resident had a written service plan that, when updated, was signed and dated by the resident's representative, the manager, and the nurse or medical practitioner who reviewed the service plan, for one of three residents sampled. The deficient practice posed a risk if the needs and services were not agreed upon before providing these services. Findings include: 1. A review of R1's medical record revealed a service plan dated June 29, 2023. The service plan identified that R1 received medication administration and personal care services. The service plan was not signed and dated by the resident's representative, the manager, and a nurse or medical practitioner who reviewed the service plan. 2. In an interview, E1 acknowledged R1's service plan was not signed by the resident's representative, the manager, and the nurse or medical practitioner who reviewed the service plan. E1 reported R1's representative refused to sign the service plan because they did not want to pay R1's outstanding bills to the facility.

Based on observation and interview, the manager failed to ensure a resident was treated with dignity, respect and consideration. The deficient practice posed a risk to resident safety. Findings include: 1. During a facility tour, the Compliance Officer observed E2 providing personal care services to R5 in a room directly off the dining room. The doors were open to the dining and living rooms. The Compliance Officer was able to see the entire bedroom from the dining room. 2. In an interview, R1 reported having to ask the caregivers to close the door frequently when changing R1's ileostomy bag. R1 also reported times when the bile from the bag burned R1's skin because the bag had not been changed overnight. R1 reported being unable to call for assistance because the call bell was out of reach. 3. In an interview, R1 reported R1 asked E2 to no longer wash R1's private areas because E2 was "too harsh." E2 said R1 smelled bad and continued to wash R1's private areas. R1 asked E1 to speak to E2 about being too harsh. 4. In an interview, R1 reported E2 said R1 was "too fat" when R1 asked E2 for food. R1 said sometimes E2 would withhold food from R1 using the same reason. 5. In an interview, E1 acknowledged there were times R4's doors remained open while the caregivers provided services. E1 reported R4's bed was pushed back far enough that only R4's feet can be seen from outside the bedroom doors. E1 reiterated that there was cloth covering on the glass doors to R5's bedroom and indicated this provided some privacy while the doors were open. 6. In an interview, E1 acknowledged R1 reportied E2 did not honor R1's request to stop bathing R1's private areas. E1 reported E2 stopped the behavior immediately after E1 addressed the issue with E2. 7. In an interview, E1 acknowledged that E2 called R1 "too fat." E1 indicated these were human relations (HR) issues that had been discussed with E2. E1 acknowledged E2 required much improvement in this area. 8. In an interview, E1 acknowledged residents had not been treated with consideration, dignity, or respect during the aforementioned incidents.

Based on observation, documentation review, and interview, the manager failed to ensure a resident received privacy in care for personal needs. The deficient practice posed a risk of a privacy rights violation to the residents. Findings include: 1. During a facility tour, the Compliance Officer observed E2 providing assisted living services to R5 in a room directly off the dining room. The doors were open to the dining and living rooms. The Compliance Officer was able to see the entire bedroom from the dining room. 2. In an interview, R1 reported asking E2 to ask R4, R1's roommate, to leave the room while R1 was being bathed or receiving other private assisted living services in bed. R1 attempted to ask R4 to leave several times, as R4 was ambulatory. However, R4 did not respond to R1's requests. R1 asked E2 for assistance on more than one occasion and E2 refused, using time constraints as the justification. 3. In an interview, E1 acknowledged there were times R4 's doors remained open while the caregivers provided services. E1 reported R4's bed is pushed back far enough that only R4's feet can be seen from outside the bedroom doors. E1 reiterated that there was cloth covering on the glass doors to R5's bedroom and indicated this provided some privacy while the doors were open.

Based on interview and record review, a manager failed to ensure a medication was administered to a resident by an individual under the direction of a medical practitioner, for one of two sampled residents. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. In an interview, R3 reported E4 administered medications to E4 sometimes at night time. 2. In an interview, E1 acknowledged E4 sometimes administered medications to residents. E4 acknowledged E4 was not administering medication under the direction of a medical practitioner. 3. A record review revealed no personnel record for E4. Therefore, there was no documentation to indicate E4 was under the direction of a medical practitioner while administering medication to R3.

Based on observation, documentation review, and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in a locked area inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During a tour of the facility, the Compliance Officer observed Comet cleaner, Palmolive dish soap,window cleaner, and Glade air freshener in an unlocked cabinet under the kitchen sink. The cabinet had two doors; one was locked and the other was not. 2. In an interview, E1 acknowledged the aforementioned toxins were stored in an unlocked cabinet accessible to residents.

Based on observation and interview, the manager failed to ensure at least one common bathroom accessible from a common area contained paper towels in a dispenser or a mechanical air hand dryer. Findings include: 1. During a facility tour, the Compliance Officer observed one common bathroom in the facility. The bathrooms did not contain paper towels in a dispenser or a mechanical air hand dryer. 2. In an interview E1 acknowledged the common bathroom did not contain paper towels in a dispenser or a mechanical air hand dryer. E1 indicated the residents clog the toilet with paper towels and this is the reason the bathroom did not contain paper towels in a dispenser.