ACE CASTLES ASSISTED LIVING, LLC

Based on documentation 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 health and safety of residents if employees were not trained to prevent or recover a resident in the event of a fall.

Findings include:

1. A review of facility policies and procedures (reviewed May 3, 2022) revealed a policy titled "Orientation and In-Service Training". The "In-Service Training" procedure section stated "...1. All training and in-service needs will be conducted and/or coordinated by the manager... The training must include but not limited to the following subjects: ... Fall and Fall Prevention recovery

2. A review of E3's and E4's personnel records revealed initial training and continued competency training in fall prevention and fall recovery was not available for review.

3. In an interview, E1 acknowledged E3's and E4's personnel records did not include fall prevention and fall recovery training.

This is a repeat deficiency from a compliance inspection conducted on March 25, 2022.

Based on observation, interview, documentation review, and record review the manager failed to establish policies and procedures to protect the health and safety of a resident covering cardiopulmonary resuscitation (CPR) training, for one of one volunteers sampled. The deficient practice posed a risk as the standards expected of volunteers in the policies and procedures were not followed; the Department was unable to determine substantial compliance as the policy and procedure was not established at the time of the inspection.

Findings include:

1. The Compliance Officer observed E4 working at the facility upon arrival on July 7, 2023.

2. In an interview, E1 reported E4 was a volunteer of AL12050.

3. A review of facility 's policies and procedures (reviewed May 3, 2022), revealed a policy titled "Cardio-Pulmonary Resuscitation (CPR) First Aid". The policy stated "The manager shall ensure that all employees of the facility have a valid Cardio-Pulmonary Resuscitation (CPR) training specific to adults documented and a copy of the certificate on file upon hiring..."

4. A review of facility 's policies and procedures (reviewed May 3, 2022), revealed a job description titled "Volunteer". The job description stated "Currently, this facility only allows volunteer services from Hospice Organization and from Church Groups..."

5. A review of E4's personnel record revealed E4 was hired as a volunteer in 2022. However, E4 did not have documentation of CPR training.

6. In an interview, E1 reported E4 did not require CPR training because E4 was a volunteer for AL12050. E1 confirmed E4 was not a volunteer with a hospice organization. E1 acknowledged the current CPR and first aid policy and the "volunteer" job description, did not cover CPR training.

Based on documentation review, record review, observation and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's completed orientation required by policies and procedures, for two of five personnel members sampled. The deficient practice posed a risk if personnel were unable to meet the resident's needs.

Findings include:

R9-10-101.155. "Orientation" means the initial instruction and information provided to an individual before the individual starts work or volunteer services in a health care institution.

1. A review of facility policy and procedures (reviewed May 5, 2022) revealed a policy titled, "Orientation and In-Service Training." The policy stated "1. All new hires will undergo orientation based on the current scope of services of the facility to assure better understanding of the services and to enable them to perform the responsibilities of their jobs in an effective and efficient manner... Orientation will be on their hire date or before their first day of work and mist be documented..."

2. A review of E3's personnel record revealed E3 was hired as an assistant caregiver in 2023. However, evidence of documentation of E3's orientation was not available for review.

3. A review of E4's personnel record revealed E4 was hired a volunteer in 2022. However, evidence of documentation of E4's orientation was unavailable for review.

4. During a tour of the facility, the Compliance Officer observed both E3 and E4 to be working and providing assisted living services to residents.

5. In an interview, E1 acknowledged documentation of E3's and E4's orientation was not available for review in the personnel record.