Prince of Peace Assisting Living LLC

Based on documentation review, record review, and interview, the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery to include continued competency. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not developed and implemented. Findings include: 1. A review of the facility's policies and procedures revealed an undated policy titled "Fall Prevention." However, a training program for all staff regarding fall prevention and fall recovery to include initial training and continued competency was not available for review. 2. In an interview, E1 acknowledged a training program for all staff regarding fall prevention and fall recovery to include initial training and continued competency was not available for review. Technical assistance was provided on this Rule during the compliance inspection conducted on August 30, 2022.

Based on record review and interview, the manager failed to ensure a resident had a written service plan signed and dated by the resident or resident's representative, for one of two residents sampled who received directed care services. Findings include: 1. A review of R5's (admitted in 2021) medical record revealed a service plan, dated in July 2023 for directed care services. The service plan was signed by R1, however, the service plan was not signed and dated by R1's representative. 2. In an interview, E1 acknowledge the service plan was not signed and dated by the resident's representative.

Based on record review and interview, the manager failed to ensure a written service plan was signed and dated by the manager, for three of three residents sampled. Findings include: 1. A review of R1's (admitted in 2021) medical record revealed an updated service plan, dated in July 2023 for personal care services. However, the service plan was not signed and dated by the manager. 2. A review of R2's (admitted in 2021) medical record revealed an initial service plan, dated in July 2023 for personal care services. However, the service plan was not signed and dated by the manager. 3. A review of R3's (admitted in 2023) medical record revealed an updated service plan, dated in July 2023 for directed care services. However, the service plan was not signed and dated by the manager. 4. In an interview, E1 acknowledged the service plans were not signed and dated by the manager.

Based on observation and interview, the manager failed to ensure foods requiring refrigeration were maintained at 41\'b0F or below. The deficient practice posed a risk for potential food borne illnesses. Findings include: 1. The Compliance Officer observed a refrigerator, in the kitchen, to store food and the refrigerator contained a thermometer. The thermometer read 50\'b0F. The Compliance Officer used a Department-issued thermometer and the refrigerator measured at 51.7\'b0F. 2. In an interview, E1 acknowledged the kitchen refrigerator temperature was not maintained at or below 41\'b0F.

Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A review of facility documentation revealed a daily staffing schedule for the month of August 2023. The schedule revealed the facility maintained two shifts: -6:00 AM - 6:00 PM (first shift) -6:00 PM - 6:00 AM (second shift) 2. A review of facility documentation revealed the following disaster drills were conducted: -September 30, 2022 - 1st shift -December 29, 2022 - 1st shift -March 30, 2023 - 1st shift -June 30, 2023 - 1st shift 3. In an interview, E1 acknowledged disaster drills had not been conducted on each shift at least once every three months. Technical assistance was provided on this Rule during the compliance inspection conducted on August 30, 2022.

Based on documentation review and interview, the manager failed to ensure documentation of each evacuation drill included the amount of time taken for employees and residents to evacuate the assisted living facility. Findings include: 1. A review of facility documentation revealed a daily staffing schedule for the month of August 2023. The schedule revealed the facility maintained two shifts: -6:00 AM - 6:00 PM (first shift) -6:00 PM - 6:00 AM (second shift) 2. A review of facility documentation revealed the following evacuation drills had been conducted: -June 30, 2022 -December 29, 2022 -June 30, 2023 However, the documentation did not include the amount of time taken for employees and residents to evacuate the assisted living facility on either of the evacuation drills conducted in June 2022 and June 2023. 3. In an interview, E1 acknowledged the evacuation drills did not contain the amount of time taken for employees and residents to evacuate the assisted living facility.

Based on observation and interview, the manager failed to ensure the premises and equipment used at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. Findings include: 1. The Compliance Officer observed the back yard contained the following: -Old tables -Old lawn equipment -Old mattresses/box springs -Old coolers -Old milk crates -Ladders -Pieces of wood with nails and screws exposed -Stacks of plastic totes -Bags of garbage and miscellaneous items -Broken medical equipment -Large tree branches -Rusted garden equipment -Building materials 2. The Compliance Officer observed numerous ambulatory residents on the premises. 3. In an interview, E1 reported the facility had recently purchased the home and were renovating the home. E1 acknowledged the stacks of items and old equipment in the back yard could be a condition or situation that may cause a resident or other individual to suffer physical injury.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area and were inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. The Compliance Officers observed an unlocked cabinet in R3's bathroom. The cabinet contained the following poisonous or toxic materials: -Glass cleaner -Disinfectant cleaner The containers contained toxic warning labels. 2. The Compliance Officer observed the back yard contained the following poisonous or toxic materials: -Tide pods -Five 5-gallon buckets of paint -Stucco -All-purpose joint compound -A 5-gallon bucket of Multi-grip bond -Three 1-gallon buckets of paint The containers contained toxic warning labels. 3. The Compliance Officers observed numerous ambulatory residents on the premises. 4. In an interview, E1 acknowledged the unlocked poisonous or toxic materials in the bathroom and back yard were accessible to residents.