Zoe's Assisted Living Home LLC

Based on documentation review and interview, the governing authority failed to review and evaluate the effectiveness of the quality management program at least once every 12 months. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1. A documentation review of the facility’s Policies and Procedures: “Review and Evaluation of the Quality Management Program Record” stated, “R9-10-803 States A. A governing authority shall: 1. Review and evaluate the effectiveness of the quality management program at least every 12 months.” 2. The “Quality Management Program Record” page was dated March 1, 2024 and signed by the governing authority. 3. There was a yellow post-it note attached to the right side of the page that had writing which read, “3/1/25 due.” 4. In an interview, E2 revealed that the post-it note was a reminder to complete the quality management review. E2 acknowledged that the quality management policy was not reviewed and evaluated in the last 12 months as required.

Based on documentation review and interview, the manager failed to ensure policies and procedures were reviewed at least once every three years and updated as needed. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. A documentation review of the facility’s Policies and Procedures signature page revealed that there was a signature and date approved line for the Governing Authority/Licensee, Initiating Manager, Reviewing Managers (x3), and Medical Practitioner or Registered Nurse (RN). 2. The Medical Practitioner or Registered Nurse signed the policy and procedure manual on March 9, 2023. 3. There were no other signatures on the policy and procedure manual. 4. In an interview, while speaking with E2 in person, the employee had E1 on the telephone. E1 revealed that the employee believed that the RN’s signature was the only one required. E1 and E2 acknowledged that the policy and procedure manual was not reviewed or signed by the governing authority.

Based on record review, documentation review, and interview, the governing authority failed to follow the facility's established fall prevention and recovery training program for two of the sampled employees. The deficient practice posed a risk if a staff member was not properly trained to assist a resident who had fallen and was unable to recover independently. Findings include: 1. A review of E1 and E2 's personnel record revealed that both employees received one hour of Fall Prevention and Recovery initial training on April 26, 2023. 2. A documentation review of the facility's Policies and Procedures: In-Service Education Section stated that "Each manager and caregiver will; as minimum, complete 12 hours of ongoing training in the following areas every 12 months from the starting date of employment. The training shall include: Fall Prevention and Recovery." 3. In an interview, E2 acknowledged that neither employee received the ongoing Fall Prevention and Recovery training as outlined in the facility's policies and procedures.

Based on record review and interview, the manager failed to ensure that a resident had a written service plan that was reviewed and updated at least once every 12-months for a resident receiving supervisory care services, at least once every six-months for a resident receiving personal care services, and at least once every three-months for a resident receiving directed care services. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of R2's medical records revealed a service plan for supervisory care services dated January 4, 2024. 2. In an interview, E2 acknowledged that a new 12-month supervisory care, six- month personal care, or three-month directed care service plan was not completed as required for R2.