Grace Manor

Based on documentation review, record review and interview, the manager failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery that included continued competency training. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. Review of facility policies and procedures revealed a document titled "Fall Prevention and Fall Recovery Policy and Procedure". This document stated "Fall Prevention and Fall Recovery Training will be included as part of personnel requirement and has to be updated at least once every 12 months." 2. Review of E1's personnel record revealed a certificate for Fall Prevention and Fall Recovery training dated January 22, 2022. However, the personnel record did not include current documentation of fall prevention and fall recovery training. 3. Review of E2's personnel record revealed a certificate for Fall Prevention and Fall Recovery training dated January 22, 2022. However, the personnel record did not include current documentation of fall prevention and fall recovery training. 4. In an interview, E1 and E3 acknowledged E1's and E2's personnel record did not contain documentation that showed E1 and E2 completed continued competency training regarding fall prevention and fall recovery.

Based on record review and interview, the manager failed to ensure that a personnel record for one of three employees reviewed included documentation of the individual's skills and knowledge applicable to the individual's job duties. The deficient practice posed a risk if an employee was unable to meet a resident's needs. Findings include: 1. Review of E2's personnel record revealed documentation of E2's skills and knowledge was not available for review. 2. In an interview, E1 and E3 acknowledged E2's skills and knowledge were not documented in the personnel record.

Based on record review and interview, the manager failed to ensure a resident accepted by the assisted living facility submitted documentation signed by a medical practitioner or a registered nurse that stated whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for one of two residents reviewed. 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 (admitted in 2022) medical record revealed no documentation that stated whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints. 2. In an interview, E1 reported that the resident was already on hospice when admitted, so E1 thought the documentation was unnecessary. E1 and E3 acknowledged R1 did not provide documentation signed by a medical practitioner or a registered nurse that stated whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints.

Based on record review, observation and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for two of two residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. Review of R1's medical record revealed a current written service plan for personal care services dated February 5, 2024. This service plan stated the following service was needed: "Nail Care: Dependent, by CG; Check fingernails to clean; check toenails after each complete bath and clean" However, documentation was not available indicating this service was provided. 2. Review of R2's medical record revealed a current written service plan for directed care services dated April 10, 2024. This service plan stated the following services were needed: "Nail Care: Dependent, by CG; Check fingernails to clean; trim fingernails PRN; check toenails after each complete bath and clean" and "Comb hair: Dependent; by CG; daily" However, documentation was not available indicating these services were provided. 3. The Compliance Officer observed that R1's and R2's fingernails looked as if the nail care was being provided and R2's hair appeared combed. 4. During an interview, E1 and E3 acknowledged R1's and R2's medical records did not include documentation of the services provided.