GOLDEN AGE CARE HOME LLC

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of medication administration for one of two residents sampled. The deficient practice posed a risk as the required information could not be verified.

Findings include:

1. A review of R1's (received medication administration) medical record revealed a signed medication order dated June 2024, for the following medications:
-Hydroxyzine 10 mg take one tablet twice a daily
-Trazodone 50 mg take one tablet daily

2. A review of R1's medication administration record (MAR) for August 2024, listed the aforementioned medications. However, the MAR did not contain the name and signature of the individual administering the medications for the 8:00 PM administration on August 25, 2024.

3. In an interview, E1 reported the medication was administered to R1, however, E1 forgot to sign the MAR. E1 acknowledged the medical record for R1 did not include documentation of medication administration.

Based on documentation review, record review, and interview, the manager failed to ensure the health care institution developed and administered 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 E1's personnel record revealed no documentation indicating fall prevention and fall recovery training was completed.

2. In an interview, E1 reviewed the identified record. E1 acknowledged the administrator failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery.

Based on record review, and interview, the manager failed to designate in writing, a caregiver who is present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present.

Findings:

1. A review of the facilities policies and procedures dated December 2021 stated "a manager's designee would have the requirements and be accountable for the assisted living facility when the manager is not present." The policy indicated a form titled "Delegation of Authority" would be completed to identify the manger's designee. The Delegation of Authority was not completed.

2. In an interview, E1 confirmed the facility did not designate in writing a caregiver as the manager's designee. E1 reported being the only certified caregiver and that E1's son is an assistant caregiver.

Based on documentation review and interview, the manager failed to implement policies and procedures (P&P's) to cove staffing and recordkeeping.

Findings include:

1. Review of a P&P, dated December 2021, and titled "Staffing and Record Keeping" revealed the following: "A work schedule is developed and shall be posted with all the staff members who provide assisted living services and maintained for at least 12 months ...the work schedule must contain name, dates, hours worked, etc.".

2. Review of the facility's work schedule for February and March 2023, titled, "Work Schedule," revealed names but no work hours for the entire months.

3. In an interview, E1 reported being the only certified caregiver and worked each day and is the live-in caregiver to cover resident needs at night. E1 acknowledged the work schedules did not contain work hours for the aforementioned months and the facility's P&P's had not been properly implemented.

Based on record review and interview, the manager failed to ensure an assistant caregiver was only assigned to provide the assisted living services the assistant caregiver had the documented skills and knowledge to perform, for one of one caregiver sampled. The deficient practice posed a risk if the caregivers were unable or to meet a resident's needs.

Findings include:

1. A review of R2's medical record revealed a service plan dated January 9, 2023. The service plan revealed R2 required catheter care services including emptying the bag twice a day.

2. In an interview, E1 reported E1 was responsible for emptying R2's catheter bag.

3. In an interview, E1 reported E1 was trained on catheter care at a different facility. However, there was no documented evidence of catheter care training for review.

Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for one of two residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan.

Findings include:

1. Review of R1's medical record revealed a current written service plan for directed care services dated March 8, 2023. This service plan stated the following services were needed:
"Transfers- requires re-positioning every 2 hours"
"Check pressure areas daily"
"Change disposable undergarment every 2 hours and PRN"
However, documentation was not available indicating these services were provided March 8th - present.

2. During an interview, E1 acknowledged R1's medical record did not include documentation of the above listed services March 8th - present, however, reported the services were provided as indicated in the service plan.