Maxi's Loving Place

Based on documentation review, record review, and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and 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. Review of the staff personnel records revealed that E6, who was hired on December 16, 2023, had no documentation of completing fall prevention and fall recovery training as required. 2. During an interview, E1 and E2 acknowledged that E6 had not completed the required fall prevention and fall recovery training.

Based on documentation review, record review, and interview, the manager failed to ensure each caregivers' 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 of E1 started November 4, 2019, E2's start date December 1, 2019. E4's start date March 10, 2022, E5's start date March 18, 2022, and E6's started December 16, 2023. These sampled caregivers' records contained no verified documentation that they had skills and knowledge to care for R1's peg-tube, and R5's catheter and wound care. 2. In an interview, E1 and E2 acknowledged there was no verified documentation available for review of the caregivers' skills and knowledge for providing peg-tube care, catheter care, and R5's wound care.

Based on record review and interview, the manager failed to ensure a resident's written service plan was reviewed and updated at least once every three months, for one of two sampled residents receiving directed care services which posed a health and safety risk to the resident. Findings include: 1. Review of R1's medical record revealed a written service plan for directed care services that had been completed on April 19, 2023, July 21, 2023, and November 9, 2023. Based on the date of acceptance, there were no other service plans available for review for the past 12 months. 2. During an interview, E1 and E2 acknowledged R1 who had been receiving directed care services for the past 12 months did not have R1's service plan updated at least once every three months.

Based on records review and interview, the manager failed to ensure that two of two sampled residents who were unable to ambulate even with assistance, the residents' primary care provider (PCP) or other medical practitioner signed a determination stating that the residents' needs were being met. This determination was to be completed at least once every six months throughout the duration of the residents' condition to determine if the resident's needs could be met. Based upon a current resident examination and the assisted living facility's scope of services which posed a health and safety risk for two of three residents' records reviewed. The facility is licensed to provided directed care services. Findings include: 1. During an interview, E2 reported that R1 and R4 have been unable to ambulate even with assistance for the past 12 months. 2. Review of R1's and R4's medical records revealed a documented determination dated November 1, 2023 during the past 12 months. There were no updated determination completed at least once every six months throughout the duration of the residents' condition to determine if the resident's needs could be met. The determination should have been based on a current resident examination and the facility's scope of services that the resident's needs could be met. 3. In an interview, E1 and E2 acknowledged there was no determination completed as required for R1 and R3 who were unable to ambulate even with assistance.