God's Grace Assisted Living LLC

Based on documentation review, record review, and interview, for one of three caregivers reviewed, the health care institution failed to administer a training program for all staff regarding fall recovery. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not implemented. Findings include: 1. A review of facility documentation revealed the facility had a Fall Prevention and Fall Recovery Program (FPFR). 2. In record review, E2's personnel record (date of hire April 8, 2024) did not include documention E2 received training on fall recovery. 3. During an interview, E1 acknowledged E2 did not receive training on fall prevention and fall recovery, as required.

Based on observation, documentation review, and interview, the governing authority failed to ensure a caregiver who was able to read, write, understand, and communicate in English was on the assisted living facility's premises. The deficient practice posed a risk if the caregiver was unable to understand and communicate with residents, and others involved in resident care and services. Findings include: 1. In observation, E2 was observed to be working at the facility, with two residents present, and no other personnel on site. 2. During an interview, E2 was unable to speak, read or write in English, and was observed using a telephone application to interpret the Compliance Officer's statements. 3. In record review, E2's personnel record indicated E2's date of hire was April 8, 2024. 4. In documentation review, the facility's staffing schedule included documentation E2 worked from 7:00am - 7:00pm as the only caregiver on shift, every Monday, Thursday, and Saturday, April 1, through April 30, 2024. 5. During an interview, the findings were reviewed with E1 and O1, who acknowledged E2 did not speak English, and was working alone with the residents at the facility.

Based on observation, documentation review, and interview, the manager failed to designate in writing, a caregiver who was present on the assisted living facility premises and accountable for the assisted living facility when the manager was not present on the assisted living facility premises. Findings include: 1. In observation, E2 was present and observed to be working at the facility, with two residents present, and no other personnel on site. 2. During an interview, E2 was unable to speak English, and was observed using a telephone to interpret the Compliance Officer's statements. 3. In record review, E2's personnel record (date of hire April 8, 2024) did not include documentation of a caregiver certificate. 4. A review of the website for caregiver certification verification revealed no caregiver certificate issued to E2. 5. During an interview, the findings were reviewed with E1 and O1, who acknowledged E2 was not a certified caregiver, did not speak English and was working alone with the residents at the facility.

Based on record review, documentation review, and interview, for one of three caregivers reviewed, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrator and Assisted Living Facility Managers (NCIA Board). The deficient practice posed a risk if a caregiver was not qualified to provide the required services, and the Department was provided false and misleading information. Findings include: 1. In observation, E2 was present and observed to be working at the facility, with two residents present, and no other personnel on site. 2. During an interview, E2 was unable to speak English, and was observed using a telephone to interpret the Compliance Officer's statements. 3. In record review, E2's personnel record (date of hire April 8, 2024) did not include documentation of a caregiver certificate. 4. A review of the website for caregiver certification verification revealed no caregiver certificate issued to E2. 5. During an interview, the findings were reviewed with E1 and O1, who acknowledged E2 did not provide documentation of completion of a caregiver training program, as required.

Based on observation, record review and interview, for seven of 12 caregivers reviewed, the manager failed to ensure a caregiver provided evidence of freedom from infectious tuberculosis (TB). The deficient practice posed a potential health and safety risk of TB exposure to residents and staff. Findings include: 1. In observation, E2 was working at the facility. 2. In record review. E2's personnel record (date of hire April 8, 2024) did not include documentation E2 provided evidence of freedom from TB, as required. 3. During an interview, E1 acknowledged the caregiver did not include not provide the required documentation of freedom from TB.

Based on observation, record review, documentation review, and interview, the manager failed to ensure at least the manager or a caregiver was present in the assisted living home when a resident was on the premises. The deficient practice posed a health and safety risk to residents who were on the premises with unqualified personnel. Findings include: 1. In observation, E2 was observed to be working at the facility, with two residents present, and no other personnel on site. 2. During an interview, E2 was unable to speak, read or write in English, and was observed using a telephone application to interpret the Compliance Officer's statements. 3. In record review, E2's personnel record indicated E2's date of hire was April 8, 2024. E2's record did not include documentation of a caregiver certificate. 4. In documentation review, the facility's staffing schedule included documentation E2 worked from 7:00am - 7:00pm as the only caregiver on shift, every Monday, Thursday, and Saturday, April 1 through April 30, 2024. 5. During an interview, the findings were reviewed with E1 and O1, who acknowledged E2 did not speak English, was not a certified caregiver, and the facility did not have a manager or caregiver present in the facility while residents were present.

Based on record review, and interview, for one of two residents reviewed, the manager failed to ensure a resident had a written service. The deficient practice posed a health and safety risk if the caregivers did not know the services the resident needed to receive. Findings include: 1. In record review, based on R2's acceptance date, R2's medical record included documentation of a Service plan form, however, the form was not completed, and signed as required, and did not include the services provided for R2. 2. During an interview, E1 acknowledged R2's record did not include a service plan, as required.

Based on record review and interview, for one of two residents reviewed, the manager failed to ensure a resident had a written service plan which was signed and dated by the resident or resident's representative, the manager, and if a review was required, by the nurse or medical practitioner (MP) who reviewed the service plan. The deficient practice posed a health and safety risk if a resident or resident's representative, and the manager, did not acknowledge the services that were to be provided. Findings include: 1. In record review, R1's medical record (received personal care and medication administration services) included a service plan dated March 80, 2024. The service plan was not signed and dated as reviewed by the resident or resident's representative and the manager. 2. During an interview, the findings were reviewed with E1, and E3, who acknowledged the service plan was not signed and dated by the resident or resident's representative, and the manager.

Based on observation, documentation review, record review, and interview, for two of two residents reviewed receiving medication administration, the manager failed to ensure a resident's medical record included the name and signature of the individual administering medication. This posed a health and safety risk to residents if the medication administered to a resident did not include the name and signature of the caregiver who administered the medication to the residents. Findings include: 1. During an interview, R1 reported [R1] was provided medication administration by E1, E2, and E3. 2. In record review, the medical records for R1, and R2, included documentation of medication administration records (MAR) for March and April, 2024. The MARs did not include the name and signature of the caregiver who administered the medications, and included only a "dash" mark on each day/time a medication was administered. 3. In documentation review, the facility's medication policies included documentation, "...10. The trained caregiver will initial in the MAR and include the date and time the medicine was given to the resident and the medications that were taken..." 4. During an interview, E1 and E3 reported R1 and R2 received medication administration daily, and acknowledged the residents' MARs did not include the name and signature of the individual's who administered medications to the residents.

Based on observation, record review, and interview, for one of two residents reviewed, who received a controlled substance, the manager failed to ensure policies and procedures were implemented for inventorying controlled substances. The deficient practice posed a risk if controlled substances were not inventoried and accounted for by the facility. Findings include: 1. In observation, R1 had Tramadol medication (a schedule IV controlled substance), and Hydromorphone medication (a schedule II controlled substance) stored by the facility. 2. In record review, R1's medical record (received personal care and medication administration services), included documentation R1 received the Hydromorphone medication on March 28, through April 15, 2024, almost daily, and received the Tramadol medication on April 19, x 1, April 23, x 2, April 24 x 3, April 25, x 2, and April 26, x 4. 3. During an interview, E1 and E3 acknowledged an inventory of R1's controlled substances was not maintained.