Starfish Care Homes, LLC

Based on document review, record review, and interview, the manager failed to ensure an assisted living facility had a manager, caregivers, and assistant caregivers with the qualifications, experience, skills, and knowledge necessary to meet the needs of and ensure the health and safety of a resident. The deficient practice posed a risk if the employees were unable to meet residents’ needs. Findings include: 1. A review of facility documentation revealed an incident report documenting an incident which occurred on May 5, 2025, involving R3. The report indicated R3 “had a fall around 0130…” The report also indicated “[E4] went to get [O1, a caregiver from a different facility] for assistance.” The report reflected the heel of R3’s shoe came off, resulting in R3 falling. 2. A review of facility staff schedules revealed E4 was the only caregiver working during the 7 p.m. to 7 a.m. shift on May 5, 2205. 3. A review of R3’s medical record revealed a document titled “Discharge Summary and Post-Discharge Plan of Care,” dated March 13, 2025. The document indicated at the date of discharge, R3 was “ambulatory with assistive device,” was “76” inches tall, weight was documented as “147.6,” and level of assistance needed was documented as “Limited assistance – resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance.” Further review of R3’s medical record revealed evidence of documentation indicating R3 required two people to assist with transfers or other mobility-related activities, was unavailable for review. Additionally, R3’s medical record contained documentation of R3’s weight on May 1, 2025, as “182 lbs.” 4. In an interview, E1 advised R3 used a wheelchair when first accepted into the facility, but had since recovered and was ambulatory, without the use of a wheelchair. E1 said on the night R3 fell, E3 was the only caregiver working at the facility, and E3 left the facility to get O1 to help lift R3 off the ground. E1 indicated O1 was a caregiver at a neighboring assisted living facility. E1 reported being aware E3 suffered from “back issues,” but said most of the time it does not affect E3’s ability to perform their duties. E1 stated they did not ask E3 why they needed assistance to render first aid to R3 when they had fallen. 5. A review of E3’s personnel record revealed E3 was a certified caregiver, hired on November 8, 2022. E3’s personnel record contained evidence of documentation indicating E3 had received, according to the facility’s program requirements, training in fall prevention and fall recovery, E3 had current training in first aid, and E3’s skills and knowledge were verified before providing assisted living services. 6. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on document review and interview, the manager failed to ensure at least one manager or caregiver was present at an assisted living home when a resident was present in the assisted living home. The deficient practice posed a risk as no qualified employee was present to meet a resident's needs. Findings include: 1. A review of facility documentation revealed an incident report documenting an incident which occurred on May 5, 2025, involving R3. The report indicated R3 “had a fall around 0130…” The report also indicated “[E4] went to get [O1, a caregiver from a different facility] for assistance.” 2. A review of facility staff schedules revealed E4 was the only caregiver working during the 7 p.m. to 7 a.m. shift on May 5, 2205. 3. In an interview, E1 advised E3 left the facility to get O1 to help lift R3 off the ground. E1 indicated O1 was a caregiver at a neighboring assisted living facility. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.