Grace's Place Assisted Living Home

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before providing physical health services and according to policies and procedures, for five of five sampled caregiver personnel records reviewed, which posed a health and safety risk. Findings include: 1. Reviewed the personnel records for E1 started July 3, 2006, E2's start date January 11, 2021. E3's start date May 1, 2010, E5's start date October 10, 2022, and E6's started March 1, 2016. These sampled caregivers' records contained no verified documentation that they had skills and knowledge to care for R7's suprapubic catheter. 2. In an interview, E1 acknowledged there was no verified documentation available for review of the caregivers' skills and knowledge for catheter care.

Based on record review and interview, the manager failed to ensure that within 90 calendar days before or on the day the individual was accepted by an assisted living facility there was completed the required documented determination. This documentation should have included whether the individual required continuous medical services and continuous or intermittent nursing services; this was based on the date of acceptance, for one of one sampled residents' records reviewed which posed a health and safety risk. Findings include: 1. Review of R1's medical record found no documentation of a pre-admission determination that should have been completed before or on the day R1 was accepted to the facility. Based on the date of acceptance this was required. 2. In an interview, E1 and E6 acknowledged the 90-day determination documentation was not completed as required.

Based on documentation reviewed and interview, the manager failed to ensure an employee disaster drill was conducted on each shift and documented which posed a safety risk. Findings include: 1. During an interview, E1 and E6 reported the facility had two shifts: First shift from 7:00 AM to 7:00 PM, the second shift from 7:00 PM to 7:00 AM. 2. Based on the documentation provided for the last 12 months, the first shift had three of the four required employee disaster drills conducted July, 2023, October 1, 2023, and January 1, 2024. 3. The second shift had two of the four required employee disaster drills conducted on April 1, 2023 and January 1, 2023. 4. In an interview, E1 and E6 acknowledged employee disaster drills were not conducted on each shift every three months as required.