Angel Hands Home Care LLC.

“Based on documentation review, record review, and interview, the health care institution failed to develop and administer a fall prevention and fall recovery training program for all staff regarding fall prevention and fall recovery, to include initial training and continued competency training, for two of two personnel sampled. Findings include: 1. A review of the facility's policies and procedures revealed no policy on the continued competency training for fall prevention and fall recovery. 2. A review of E1's personnel record revealed annual documentation of fall prevention and recovery training for the years 2022 through 2024. However, documentation of E1's annual fall prevention and fall recovery training in 2025 was not available for review. 3. A review of E2's personnel record revealed documentation of fall prevention and fall recovery training for 2022; no documentation was available for review for any of the years following. 4. In an exit interview with E1, the findings were reviewed, and no additional information was provided.”

“Based on documentation review and interview, the health care institution’s chief administrative officer failed to implement tuberculosis (TB) infection control activities that annually assessed the health care institution’s risk of exposure to infectious tuberculosis, and annual training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed. Findings include: 1. A review of the facility’s annual TB facility risk assessment documentation revealed years 2023 and 2024, but no documentation for 2025. 2. A review of E1's personnel file revealed documentation of annual training and education related to recognizing the signs and symptoms of tuberculosis for 2023 and 2024, but no documentation was available for 2025 or years prior. 3. A review of E2's personnel file revealed documentation of annual training and education related to recognizing the signs and symptoms of tuberculosis for 2025, but no documentation was available for years prior. Based on E2's hire date, this documentation was needed. 4. In an interview, E1 was unsure if the facility completed a yearly facility risk assessment; E1 was able to find documentation for the years mentioned prior. 5. In an exit interview, findings were reviewed with E1, and no additional information was provided.”

“Based on document review and interview, the manager failed to ensure that a plan was implemented for an ongoing quality management program that included: a method to identify, document, and evaluate incidents, a method to collect data to evaluate services provided to residents, a method to evaluate the data collected to identify a concern about the delivery of services related to resident care, a method to make changes or take action as a result of the identification of a concern about the delivery of services related to resident care, and the frequency of submitting a documented report required in subsection (2) to the governing authority. 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 review of the facility's documents revealed no quality management program documentation. 2. A review of the facility's policies and procedures revealed the following policies: A policy titled, "Quality Management Program." This policy stated," In order to provide quality and safe services to the facility residents, the manager will ensure that: 1. Methods to identify, document, and evaluate incidents are available for all facility employees as per procedure below. 2. Methods to evaluate services provided to residents are used properly as per procedure below. 3. Methods to evaluate the data collected to identify a concern about the delivery of services related to residents care are available as per procedure below. 4. A method to make changes or take action as a result of the identification of a concern about the delivery of services related to residents' care is available as per procedure below. 5. Documentation of all reports made in regards to the resident care will be submitted to the governing authority. PROCEDURES: All facility employees will be trained using basic common sense to observe constantly the residents and their behavior. 6. The facility manager will review on a daily basis residents' records to ensure that the residents are provided necessary assisted living services, including medication services, according to the residents' service plan, safety of the residents is assured at all times. 10. Once a month the manager will report to the governing authority/licensee all the concerns about the delivery of services related to the residents care and any change made or action taken as a result of the identification of a concern about the delivery of services related to residents care. The manager or Designee shall document monthly: a. number/type of incidents; b. Patterns across residents; c. Number of residents experiencing falls d. Number of residents experiencing weight loss; e. Number of residents with decubitus ulcers; f. Number of residents with possible HCAIs; g.Number of residents reporting the loss of personal property/clothing; h. Number of errors in the documentation of medications (MARs), treatments, ADLs, ect. provided to residents. 11. Maintain a line graph for each of the above to identify trends from month to month. 14. The manager is responsible to maintain and store the reports caused to the governing authority/licensee for at least 12 months from the reporting date. 3. A review of the document request form revealed that the Compliance Officer requested the facility's quality management documents at 11:10 am; however, documentation was not available during the inspection. 4. In an interview, E1 reported that they were unaware that a quality management program was needed, and E1 reported having no quality management documentation. 5. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on documentation review, record review, and interview, the manager failed to ensure that a caregiver’s skills and knowledge were verified and documented before the caregiver provided physical health services, for one of two personnel sampled. The deficient practice posed a risk if the employees were unable to meet a resident's needs. Findings include: 1. A review of the facility’s policies and procedures revealed a policy titled "Caregiver and Volunteer”. The policy stated, “ 1. In order to provide adequate care to the residents it is required that each employee and volunteer are knowledgeable of their job description and duties. 2. Each employee meets the qualifications, required skills, education knowledge and experience. Procedures: The hiring person or manager will ensure, check and document that each caregiver or assistant caregiver providing health services or behavioral health services have the required skills and knowledge before providing any service." 2. A review of the facility's employee schedule revealed E2 worked daily, Monday through Sunday, 6:00 pm to 6:00 am. 3. A review of E2's personnel record revealed E2 was hired as a caregiver with a hire date of September 1, 2023. 4. In an interview, E1 reported being unsure of the process to verify skills and knowledge for employees per the facility's policies and procedures. E1 reported that the policies and procedures should contain all information needed for the compliance inspection. 5. Further review of E2's personnel record revealed no documentation of E2's skills and knowledge before providing physical health services. 6. In an exit interview the findings were reviewed with E1, and no additional information was provided.”

“Based on observation, documentation review, and interview, the manager failed to ensure at least the manager or a caregiver was present at an assisted living home when a resident was present in the assisted living home. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. After arriving on-site the Compliance Officer observed a sign that stated, "To whom it may concern residents attending day care program please contact manager thank you." 2. While on-site, the Compliance Officer observed the following: The Compliance Officer knocked on the facility door and could hear a person inside, but was not allowed entry. At 10:15 am the Compliance Officer called E1, whose number was listed on the aforementioned sign. E1 answered the phone and reported they would be arriving at the facility momentarily. Approximately 3 minutes later, E1 arrived at the facility. E1 was unable to access the facility through the front entrance and had to gain access through the facility's side gate. Once inside, E1 went into R1's room to make R1 aware that the Compliance Officer was on-site. 3. In an interview, E1 reported that there was no caregiver on site with R1 when the Compliance Officer arrived. 4. In an exit interview, findings were reviewed with E1, and no additional information was provided.”

“Based on documentation review, record review, and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident's date of occupancy and as specified in R9-10-113, for one of two residents sampled. The deficient practice posed a TB exposure risk to residents. Findings include: 1. R9-10-113(A)(2)(a)(i-iii) states: "A. If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is…admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)." 2. A review of the facility’s policies and procedures revealed a policy titled "Infection Control ." This policy stated," 1. All employees and residents of this facility are required to provide one of the following on admission and annually thereafter. a. A report of a negative Mantoux Tuberculin (TB) skin test within 6 months of the date of employment or residence in the facility. 2. Employment or admission will be contingent upon compliance with the screening parameters of the policy." 3. A review of R2's medical record revealed no documentation of R2's freedom from infectious tuberculosis. Based on R2's admission date, this documentation was needed. 4. In an exit interview, findings were reviewed with E1, and no additional information was provided.”

“Based on record review, document review, and interview, the manager failed to ensure that each resident had a service plan that was established, documented, and implemented, and when updated, was signed and dated by the resident or the resident's representative, for two of two sampled residents. Findings include: 1. A review of R1's medical record revealed a service plan dated January 19, 2026, which revealed R1 received directed care services. The service plan was signed and dated by the manager, a nurse, and the resident. Based on R1's level of care, a signature from R1's representative was required. 2. A review of R2's medical record revealed a service plan dated January 19, 2026, which revealed R2 received directed care services. The service plan was signed and dated by the manager, a nurse, and the resident. Based on R2's level of care, a signature from R2's representative was required. 3. In an interview, E1 reported that they were unaware that signatures were needed from residents' representatives for residents who receive directed level of care services. E1 also reported that it was difficult to coordinate with the residents' representatives to obtain signatures. 4. In an exit interview with E1, the findings were reviewed, and no additional information was provided.”

“Based on observation, documentation review, and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to residents who were unable to self-administer medications.  Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed the following: In the shared patient bathroom, a bottle of Ketoconazole cream 2%, a tube of Triamcinolone Acetonide cream 0.1%, and a tube of Silver Sulfadiazine cream 1%. The magnetic key to the kitchen cabinet, where all resident medications were stored, was kept on the cabinet door, making the medications accessible. 2. In an interview, E1 reported that it was easier to keep these medications in the unlocked bathroom cabinet for everyday use. 3. In an exit interview, findings were reviewed with E1, and no additional information was provided.”

“Based on documentation review and interview, the manager failed to ensure the disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies the standards expected of employees. Findings include: 1. A review of the facility’s disaster plan documentation revealed documentation of an annual disaster plan review completed in 2018. However, documentation of additional reviews was not available. 2. A review of the facility’s policies and procedures revealed no policy on the facility's disaster plan. 3. In an exit interview, the findings were discussed with E1, and no additional information was provided.”

“Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in labeled containers 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. During an environmental tour, the Compliance Officers observed the following: In an unlocked cabinet in the facility kitchen, there was a bottle of Oxi Clean dishwasher detergent and a bottle of Extreme Tire Shine. In an unlocked employee room, a bottle of pink perfume, a bottle of white diamonds spray, and a bottle of medicated baby powder. In an unlocked cabinet in the shared resident bathroom, a bottle of Veterinary Liniment Gel topical analgesic, and a cleaning bottle, unlabeled with a purple liquid inside. In the backyard of the facility two cans of spray paint on the ground near the perimeter fence. 2. In an interview, E1 reported that the spray bottle containing the purple liquid in the resident bathroom was a disinfectant spray. 3. In an exit interview, findings were reviewed with E1, and no additional information was provided.”

“Based on documentation review and interview, the manager failed to establish, document, and implement policies and procedures to protect the health and safety of a resident to cover qualifications, including required skills and knowledge, education, and experience for employees and volunteers. Findings include: 1. A review of the facility's policies and procedures revealed no documentation of a policy covering how a caregiver's or assistant caregiver's skills and knowledge are verified and documented. 2. In an interview, E1 acknowledged a policy and procedure covering how a caregiver's or assistant caregiver's skills and knowledge are verified and documented was not available for review at the time of the inspection.”

“Based on documentation review, record review and interview, the manager failed to ensure a personnel record for each employee included valid documentation of cardiopulmonary resuscitation training (CPR) and first aid training, for one of two employees sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. A review of facility documentation revealed a policy titled "First Aid and CPR Training." The policy stated "Method and content of CPR training which includes the ability to perform and demonstrate cardio-pulmonary resuscitation." 2. A review of E2's personnel record revealed a CPR and first aid training certification from "NationalCPRFoundation" dated December 13, 2023. However, training from "NationalCPRFoundation" is online only and does not include a demonstration of the employee's ability to perform CPR. 3. In an interview, E1 acknowledged E2's CPR and first aid training was completed online and did not include a demonstration of E2's ability to perform CPR.”