AMBER CREEK MEMORY CARE COMMUNITY

Based on documentation review, record review, and interview, the manager failed to ensure the health care institution 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, if staff had not received the training.

Findings include:

1. In documentation review, the facility had documentation of a training program for fall prevention and fall recovery.

2. In record review, the personnel records for E1, E2, E3, E4, E5, E6, E7, E8, E9, E10, and E11 did not include documentation the personnel completed fall prevention and fall recovery training.

3. In an interview, the findings were reviewed with E1, who reported the facility had a fall prevention and fall recovery program in place; however, the personnel had not yet been trained.

Based on record review, and interview, for one of eleven employees reviewed, the manager failed to ensure a caregiver provided documentation of current cardiopulmonary resuscitation training (CPR) certification.

Findings include:

1. In record review, the personnel record for E2 (hired on February 14, 2017) included documentation of CPR certification, with an expiration date of March 2023.

2. In an interview, the findings were reviewed with E1 and E2. E1 reported the CPR certification in E2's personnel record was the most recent update, and E2 did not have current CPR certification.

Based on observation, record review and interview, for one of twelve employees reviewed, the manager failed to have a personnel record for an employee or volunteer, as required by this Article. The deficient practice posed a risk to resident health and safety if the facility did not obtain documentation showing a volunteer met the requirements to provide services for the residents.

Findings include:

1. In observation, E12 was observed working at the facility in the kitchen preparing food.

2. In record review, the facility did not have a personnel record for E12.

3. In an interview, E1 and E5 reported E12 was an "agency" staff, provided to work as the facility, on as needed basis. E1 was not aware a personnel record was required for an agency dietary personnel.

Based on record review and interview, for two of five residents reviewed, the manager failed to ensure a resident's written service plan included a description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments. The deficient practice posed a risk to a resident if the service plan did not include a description of the resident's condition, for which services were to be provided.

Findings include:

"Service plan" means a written description of a resident's need for supervisory care services, personal care services, directed care services, ancillary services, or behavioral health services and the specific assisted living services to be provided to the resident.

1. In record review, R2's medical record included a face sheet, which documented diagnoses as "Vascular Dementia with Behavioral Disturbances, Hypertension, Overactive Bladder, Glaucoma, Hyperlipidemia, Vitamin D Deficiency, and Supra Ventricular Tachycardia."

2. R2's record included a "Resident Negotiated Service Plan," dated February 14, 2023. The service plan documented R2 required cueing and set up for eating, a Pureed diet with thicken liquids, assistance with dressing, oral care, bathing, toileting, ambulation, transfers, and medication administration. R2's service plan did not include a description of R2's medical and health problems.

3. In record review, R4's medical record included a document titled, "Diagnosis List," which documented diagnoses as "ARFF, Dementia with Behavioral Disturbance... Muscle weakness, Unspecified abnormalities of gait mobility... Psychotic Disturbance, Anxiety..."

4. R4's record included a "Resident Negotiated Service Plan," dated November 23, 2022. The service plan documented R4 required cueing and set up for eating, dressing, assistance with oral care, bathing, toileting, ambulation (had a recent Femur fracture). R4's service plan did not include a description of R4's medical and health problems, other than the recent Femur fracture.

5. In an interview, the findings were reviewed with E1 and E2, who reported R2 and R4 received directed care services. E1 and E2 acknowledged the service plans did not include a description of the residents' medical and health problems, as required.

This is a repeat deficiency from the compliance inspection conducted on April 7, 2022.

Based on record review and interview, for four of five residents reviewed, the manager failed to ensure a resident's written service plan was reviewed and updated at least once every three months, for a resident receiving directed care services. The deficient practice posed a risk if a resident's service plan was not updated as required to reinforce and clarify services.

Findings include:

1. In record review, R1's medical record included a service plan for directed care services, dated August 29, 2022. The medical record did not include documentation the service plan was reviewed and updated at least once every three months.

2. In record review, R3's medical record included a service plan for directed care services dated February 17, 2022, and August 29, 2022. The medical record did not include documentation the service plan was reviewed and updated at least once every three months.

3. In record review, R4's medical record included a service plan dated November 23, 2022. The service plan did not include R4's need for directed care services; however, R4's record included documentation R4 had Dementia. The facility is a memory care facility, and all residents received directed care services.

4. In record review, R5's medical record included a service plan for directed care services dated February 10, 2022. The medical record did not include documentation the service plan was reviewed and updated at least once every three months.

5. In an interview, the findings were reviewed E1 and E2, who reported the residents received directed care services, and the service plans were not updated every three months, as required.

Based on record review and interview, for four of five residents reviewed, the manager failed to ensure a resident had a written service plan which was signed and dated by the resident or resident's representative, the manager, and if a review was required, by the nurse or medical practitioner (MP) who reviewed the service plan. This posed a health and safety risk if the resident or resident's representative, the manager, and the resident's MP or nurse did not acknowledge the services that were to be provided.

Findings include:

1. In record review, R1's medical record (received directed care and medication administration services) included a service plan dated August 29, 2022, which was not signed and dated as reviewed by the resident or resident's representative, the manager and the MP or nurse.

2. In record review, R2's medical record (received directed care and medication administration services) included a service plan February 14, 2023, which was not signed and dated as reviewed by the MP or nurse.

3. In record review, R3's medical record (received directed care and medication administration services) included a service plan dated August 29, 2022, which was not signed and dated as reviewed by the resident or resident's representative, the manager and the MP or nurse.

4. In record review, R4's medical record (received directed care and medication administration services) included a service plan dated November 23, 2022, which was not signed and dated by the resident or resident's representative, or the manager.

5. In an interview, the findings were reviewed with E1 and E2, who acknowledged the service plans were not signed and dated by the resident or resident's representative, the manager, and signed and dated as reviewed by the nurse or MP, as required.

This is a repeat deficiency from the compliance inspection conducted on April 7, 2022.

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, which posed a health and safety risk to residents if the employees were unable to implement the disaster plan.

Findings include:

1. In documentation review, the facility had documentation, titled "fire drills", which were conducted on January 5, 2023, on the first shift, February 9, 2023, on the second shift, March 5, 2023, on the 1st shift, and April 5, 2023, on the third shift. The facility did not have documentation a disaster drill had been conducted every three months on each shift. No documentation was provided for disaster drills conducted prior to January 5, 2023.

2. In an interview, E1 reported the facility had three shifts: 6:00am - 2:00pm, 2:00pm - 10:00pm, 10:00pm - 6:00am. E1 reported being unable to locate disaster drills conducted prior to January 6, 2023, and acknowledged disaster drills were required to be conducted with employees, on each shift at least once every three months.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months; and included all individuals on the premises except for a resident whose medical record contained documentation that evacuation from the assisted living facility would cause harm to the resident. The deficient practice posed a health and safety risk to residents and employees if the employees were unable to implement the evacuation plan.

Findings include:

1. In documentation review, the facility provided documentation of an evacuation drill conducted on March 15, 2023. The facility did not have documentation an evacuation drill had been conducted six months prior. The documentation of the drill conducted on March 15, 2023, did not indicate that all individuals on the premises were included in the evacuation drill, and if any residents were not evacuated.

2. In an interview, the findings were reviewed with E1, E2, and E7. E1 reported not being able to locate documentation of an evacuation drill conducted six months prior to March 15, 2023. E1 and E7 reported all individuals on the premises were included in the evacuation drill; however, acknowledged the documentation did not include this information.

Based on documentation review and interview, the manager failed to ensure documentation of each evacuation drill included the time taken to evacuate the facility, any problems encountered in conducting the evacuation drill, and recommendations for improvement, if applicable.

Findings include:

1. In documentation review, the facility's documentation of an evacuation drill conducted on March 15, 2023, did not include the time taken to evacuate the facility, any problems encountered in conducting the evacuation drill, and recommendations for improvement, if applicable.

2. In an interview, the findings were reviewed E1, E2, and E7, who acknowledged the documentation of the evacuation drill did not include the required documentation.