Kivel Manor Assisted Living Center.

“Based on record review, documentation review, and interview, the manager failed to ensure that when a service plan was initially developed, it was signed and dated by the resident or resident's representative (POA) for one of two residents reviewed. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements.     Findings include:     1. A review of R1's medical record revealed a service plan dated January 29, 2025. The service plan was signed by all required individuals except for R1's POA (O1).     2. In an interview, E1 and E2 reported E3 used information provided by O1 to assist with developing the service plan; however, by the time the service plan was completed, O1 had already left the facility, and therefore was not able to sign at the time. Although O1 had come to the facility on numerous occasions to visit R1, O1 came in the evening when the administrative team was gone.     3. A review of Department documentation revealed O1 was aware of at least some of the services provided to R1 as O1 quoted R1's shower schedule as being on Mondays and Thursdays, which correlated with the service plan reviewed by the Compliance Officer. O1 also expressed concerns of R1 not receiving any oral hygiene because O1 noticed R1's breath "was increasingly bad" and "buildup was evident." The Compliance Officer also observed that the facility had seemingly heard O1's concerns as there was an update noted on the service plan in the oral hygiene sections that stated, "Staff will direct to brush longer."     4. In an interview, E1 and E2 reported not realizing O1 had not signed the service plan until the day of the inspection. E3 was unable to be interviewed and explain why the service plan had not been signed because E3 was out on a scheduled day off. E1 and E2 could only assume that E3 did not get the service plan signed because O1 tended to visit in the evenings when E3 was not at the facility. However, E1 and E2 agreed the service plan should have been signed by R1, and acknowledged it had not been.”

“Based on documentation review, record review, and interview, the governing authority failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk if facility staff were not properly trained to assist a resident who had fallen and was unable to recover independently. Findings include: 1. A review of facility documentation revealed a training program for all staff regarding fall prevention and fall recovery was not available for review. 2. A review of personnel records revealed fall prevention and fall recovery training completed for all employees. 3. In an interview, E1 acknowledged a documented training program for all staff regarding fall prevention and fall recovery was not available for review at the time of the inspection.”