Grace Hill Special Care, LLC

Based on documentation review and interview, the manager failed to ensure documentation of the caregivers and assistant caregivers who worked each day, including the hours worked by each, was maintained. The deficient practice posed a risk if there was not sufficient staff to ensure the health and safety of residents. Findings include: 1. A review of facility documentation revealed a "Employee work schedule" dated from December 20, 2023 through January 28, 2024. However, documentation of an "Employee work schedule" after January 28, 2024 was not available for review. 2. In an interview, E1 acknowledged documentation of the caregivers and assistant caregivers who worked each day, including the hours worked by each, was not maintained after January 28, 2024. This is a repeat citation from the previous compliance inspection conducted on April 11, 2022.

Based on documentation review, record review, and interview, the manager failed to ensure a written service plan was reviewed and updated at least once every six months for a resident receiving personal care services, for two of three residents sampled. The deficient practice posed a risk if the service plan did not include current, accurate information. Findings include: 1. A review of facility documentation revealed a policy titled "Developing and Updating Service Care Plans." The policy stated "Is reviewed and updated...at least once every six months for a resident receiving personal care services..." 2. A review of R1's medical record revealed R1 received personal care services. R1's medical record contained service plans dated May 26, 2023 and July 1, 2023. However, an updated service plan completed within six months after July 1, 2023 was not provided for review. 3. A review of R2's medical record revealed R2 received personal care services. R2's medical record contained service plans dated May 27, 2022 and May 10, 2023. However documentation of a service plan between May 27, 2022 and May 10, 2023, and within six months after May 10, 2023, was not provided for review. 4. In an interview, E1 acknowledged R1's and R2's written service plans were not reviewed and updated at least once every six months.

Based on observation, record review, and interview, the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available and accessible in a bedroom being used by a resident receiving personal care services. The deficient practice posed a risk if employees were unaware of or unable to respond to a resident needing assistance. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed R1's and R2's bedrooms did not have a bell, intercom, or other mechanical means to alert the employees to a resident's needs or emergencies. 2. A review of R1's and R2's medical records revealed R1 and R2 received personal care services. 3. In an interview, E1 acknowledged R1's and R2's bedrooms did not have a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies.

Based on observation, record review, and interview, the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available and accessible in a bedroom being used by a resident receiving directed care services. The deficient practice posed a risk if employees were unaware of or unable to respond to a resident needing assistance. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed R3's bedroom did not have a bell, intercom, or other mechanical means to alert the employees to a resident's needs or emergencies. 2. A review of R3's medical record revealed R3 received directed care services. 3. In an interview, E1 acknowledged R3's bedroom did not have a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies.