GOLDEN AUTUMN ADULT CARE HOME LLC

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.

Findings include:

1. A review of the facility's policies and procedures revealed the most recent documented review was conducted on January 7, 2021. No additional documentation to indicate the policies and procedures were reviewed at least once every three years was available for review.

2. In an interview, E1 acknowledged there was no documentation to indicate the policies and procedures were reviewed at least once every three years.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training, before providing assisted living services, for one of three caregivers reviewed. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency.

Findings include:

1. Review of the facility's policy and procedure revealed a policy titled "First Aid and CPR Training" reviewed and signed in January 2021. This policy stated "have valid First Aid/CPR training...the documentation must be current and renewed before the date of expiration noted on the card...no personnel will be able to provide services to a resident with an expired or invalid First Aid/ CPR documentation".

2. The compliance officer was greeted by E2 who was the only caregiver on duty upon arrival.

3. Review of E2's personnel record revealed E2 worked as a caregiver and had a hire date of January 2021. The personnel record revealed a first aid/CPR card with an expiration date of March 3, 2024. There was no other documentation of first aid/CPR training in E2's record.

4. Review of the March 2024 personnel schedule revealed E2 worked Monday through Friday from 7:00 am - 3:00 pm..

5. In an interview, E1, acknowledged E2 did not have current documentation of first aid/CPR training.

Based on record review and interview, the manager failed to ensure a medication was administered to a resident under the direction of a medical practitioner, for one of two residents reviewed. The deficient practice posed a risk as medication administration was being completed by individuals who had not been approved by a qualified individual to provide medication administration services.

Findings include:

1. Review of R1's medical record revealed a current written service plan dated March 2, 2024. This service plan indicated R1 received medication administration. Review of R1's medical record revealed medications were administered by facility caregivers. However, documentation from a medical practitioner stating a manager or caregiver could administer medications was not available.

2. Review of E1 and E2's personnel records revealed no documentation from a medical practitioner stating medications could be administered by a manager or caregiver or that E1 and E2 were nurses.

3. In an interview, E1 acknowledged the facility caregivers provided medication administration services to R1 without designation and authorization by a medical practitioner to administer medications to the resident.

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a locked room, closet, cabinet, or self-contained unit; which posed a health and safety risk.

Findings include:

1. During a facility tour, E2 and the compliance officer observed the office does not contain a door. In the office is a tall cabinet where medications were stored for all eight residents. The cabinet was not locked as the key was in the keyhole and could easily be opened.

2. In an interview, E1 and E2 acknowledged the medications were not stored in a locked cabinet which posted a health and safety risk.

Based on documentation review and interview, the manager failed to ensure an employee disaster drill was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement the disaster plan.

Findings include:

1. Review of the March 2024 personnel schedule revealed three shifts; 7am-3pm; 8am-4pm; and 4pm-7am.

2. Review of the facility's employee disaster drills revealed a drill conducted as follows:
January 3, 2023 at 7pm,
April 2, 2023 at 9am,
July 1, 2023 at 4pm, and
October 1, 2023 at 6:30pm.

No other employee disaster drills were available for review.

3. During an interview, E1 acknowledged the employee disaster drills were not conducted on each shift at least once every three months.

Based on observation and interview, the manager failed to ensure oxygen containers were secured in an upright position. The deficient practice posed a potential explosion or leak of a compressed gas.

Findings include:

1. During an environmental inspection of the facility with E2, the Compliance Officer observed one large oxygen tank unsecured in the facility office.

2. In an interview, E1 and E2 acknowledged the oxygen tank was not secured in an upright position.

Based on documentation review, record 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 physical health and safety of a resident.

Findings include:

1. A review of facility documentation revealed no documented policy for fall prevention and fall recovery.

2. A review E1's, E2's, and E3's personnel records revealed no documentation of fall prevention and fall recovery training

3. In an interview, E1 acknowledged E1, E2, and E3 did not have documentation of fall prevention and fall recovery training.

Based on record review and interview, the manager failed to ensure written service plans include the level of medication assistance for two of two residents reviewed, which posed a health and safety risk.

Findings include:

1. Review of R1's medical record revealed a written service plan for directed care services dated November 2022. This service plan did not include the level of medication administration R1 received.

2. Review of R2's medical record revealed a written service plan for directed care services dated September 2022. This service plan did not include the level of medication administration R2 received.

3. During an interview, E1 reported the facility stored and controlled R1 and R2's medications. E1 reported R1 and R2 received directed care services and received medication administration. E1 acknowledged R1 and R2's service plan did not include the level of medication assistance.

This is a repeat deficiency from the compliance survey conducted on September 20, 2021.

Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for two of two residents reviewed. 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 record revealed a current written service plan for directed care services dated November 2022. This service plan stated the following service was needed:
"Incontinent checks every two hours/PRN"
However, documentation was not available indicating the service was provided.

2. Review of R2's record revealed a current written service plan for directed care services dated September 2022. This service plan stated the following service was needed:
"Incontinent checks every two hours/PRN"
However, documentation was not available indicating the service was provided.

3. During an interview, E1 acknowledged R1 and R2's medical record did not include documentation of the above listed services and reported the services were provided as indicated in the service plan.