Summer Blossoms Assisted 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. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of facility documentation revealed an undated policy titled, "Fall Prevention and Fall Recovery Training." The policy indicated the training program was to be completed by all staff initially and then again once every year to maintain continued competency. 2. A review of E2's personnel record revealed no documentation of fall prevention and fall recovery training. 3. In an interview, E1 reported to be unaware E2 required fall prevention and fall recovery training due to E2's job position as a cook and housekeeper.

Based on observation, record review, documentation review, and interview, the manager failed to ensure policies and procedures were established, documented, and implemented to protect the health and safety of a resident that covered job descriptions, duties, qualifications, including required skills and knowledge, education and experience for employees and volunteers. The deficient practice posed a risk as policies and procedures reinforce and clarify the health care institution's standards. Findings include: 1. During a tour of the facility, the Compliance Officer observed E2 cooking the lunch meal for the residents and completing houseking duties around the facility. 2. A record review revealed E2's job title was a housekeeper/cook. 3. A documentation review revealed no job description for a housekeeper or cook. 4. In an interview, E1 acknowledged there was no job descriiption established or documented that covered the duties, qualification, including required skills and knowledge, education and experience for a housekeeper or cook.

Based on record review, documentation review, and interview, the manager failed to ensure before providing assisted living services to a resident, one of one sampled caregiver received orientation that was specific to the duties to be performed by the caregiver. The deficient practice posed a risk to the health and safety of residents if caregivers were not orientated to the specific duties to be performed. Findings include: 1. A review of E2's personnel record revealed no documentation of completed orientation that was specific to the duties to be performed by E2. 2. A documentation review revealed a policy and procedure titled, "Employee Orientation and [Continuing Education Units]." The policies and procedures were signed August 1, 2020. The policy indicated the manager was responsible for ensuring "new employees are provided with training on the items listed on the New Employee Orientation form before they begin their regular job duties...After receiving the New Employee Orientation employees will receive additional training specific to their job position..." 3. In an interview, E1 reported to believe E2 completed orientation that was specific to the duties in their job description. E1 reported E2 began providing assisted living services following orientation. However, no documentation was available for review.

Based on documentation review and interview, the manager failed to ensure as part of the policies and procedures required in R9-10-803(C)(1)(h), a plan was established and documented to ensure the manager or a caregiver was available as back-up to provide assisted living services to a resident if the manager or a caregiver assigned to work was not available or not able to provide the required assisted living services. The deficient practice posed a risk as there were no policies and procedures to reinforce and clarify the health care institution's standards. Findings include: 1. A review of the facility policies and procedures revealed a policy titled "Staffing Policy." The policies and procedures were signed August 1, 2020. However, a plan was not established and documented to ensure the manager or a caregiver was available as back-up to provide assisted living services to a resident if the manager or a caregiver assigned to work was not available or not able to provide the required assisted living services. 2. A review of the facility's daily staffing schedules (dated June 2023-August 2023) revealed no back-up caregiver or manager was included. 3. In an interview, E1 acknowledged the facility did not have a documented plan regarding having a back-up caregiver.

Based on documentation review, observation, and interview, the manager failed to ensure for a facility authorized to provide directed care services, there was a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort and provided access to an outside area which allowed the resident to be at least 30 feet away from the facility and controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. During a tour of the facility with E1, the Compliance Officer observed when exiting from the patio door to the backyard, no alarm sounded to alert employees of the egress of a resident from the facility. The Compliance Officer observed an alert system was installed on the patio door. However, the alert system was not functioning. 3. During a tour of the facility with E1 and E2, the Compliance Officer observed when exiting from the front door to the front yard, no alarm sounded to alert employees of the egress of a resident from the facility. 4. During a tour of the facility with E1, the Compliance Officer observed the aforementioned doors allowed residents to be at least 30 feet away from the facility. 5. In an interview, E1 reported the facility used a bar in the sliding patio door track to secure it from inside the facility. The Compliance Officer observed the bar was not in use during the tour of the facility. E1 acknowledged the aforementioned doors did not alert employees of the egress of a resident from the facility.

Based on documentation review and interview, the manager failed to ensure the disaster plan required in subsection (A)(1) was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. A review of the facility's policies and procedures revealed the facility's undated disaster plan. 2. In an interview, E1 reported the disaster plan was developed August 1, 2020. E1 was unaware of the Rule requiring a review of the disaster plan at least once every 12 months.

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 and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A review of the facility's documentation revealed no disaster drills for employees dated after 2021. 2. In an interview, E1 acknowledged there were no documented disaster drills for employees dated after 2021.