GOLDEN POND LLC

Upon identification of the deficiency, the Health and Wellness Director (HWD) immediately reviewed the medication records and physician orders for Residents #4, #5, #8, #9, #10, #17, and Former Resident #19. For Resident #9, all medications identified as unavailable due to pending delivery were reviewed with the prescribing practitioner and pharmacy. Orders were reconciled, medications were obtained, and administration resumed according to practitioner orders. The HWD completed a clinical review for each affected resident to determine whether any adverse outcomes occurred as a result of missed medications. Practitioner notification and resident monitoring were completed as indicated. Identification of Other Residents Who May Be AffectedThe HWD and care leadership team completed an audit of all current resident medication orders, medication carts, emergency medication supplies, pharmacy refill reports, and medication administration records to identify any medications that were unavailable, pending delivery, or at risk of being missed. Any discrepancies identified during the audit were corrected immediately through physician notification, pharmacy coordination, medication reordering, and staff follow-up. Measures Put Into Place to Prevent RecurrenceThe community has implemented the following system changes:Reeducation has been provided to all QMAPS regarding unavailable medication- QMAPs to verify medication availability during every medication pass and immediately report medications with fewer than seven days remaining. A weekly medication inventory audit will be completed by care leadership or designee to identify medications requiring refill and ensure adequate medication supply is maintained. The HWD, nurse, or designee will review pharmacy refill exception reports, pending deliveries, and medications awaiting authorization a minimum of three times per week. If a medication is unavailable, staff must immediately notify the MCC, ALC or nurse and document the reason for non-administration and contact the pharmacy. A Medication Shortage Log will be used during weekly medication audits to document:Medication nameResident nameDate shortage identifiedPharmacy contactedPractitioner notificationResolution dateFollow-up actions takenAll QMAPs will receive re-education regarding:Medication ordering responsibilitiesRefill proceduresDocumentation requirementsPractitioner order compliance requirements under Chapter 7, Part 14.21Escalation procedures when medications are unavailableCare leadership team will provide re-education to any resident/POA who provides their own medication. Education will include verbiage from our contract indicating:If residents procure their own medication through an alternate pharmacy, and such medication will not be delivered to the Community by the time it needs to be administered, the resident agrees that the facility may obtain that medication through our contracted pharmacy and the resident will be responsible for paying our contracted pharmacy for that medication. Golden Pond will assess a $250.00 medication order fee, per medication, per occurrence in addition to the cost of the medication. Care leadership will review any circumstance in which a resident-provided medication is unavailable due to factors outside of the resident's or responsible party's control, including but not limited to insurance authorization delays, pharmacy supply shortages, manufacturer backorders, shipping delays, prescribing practitioner delays, or other unforeseen circumstances. In these situations, the community will work collaboratively with the resident, responsible party, prescribing practitioner, and pharmacy to obtain the medication as quickly as possible and ensure continuity of care. The community will evaluate each situation on a case-by-case basis before assessing any medication ordering fees. If the medication unavailability is determined to be outside the control of the resident or responsible party, the Administrator or Health and Wellness Director may waive the medication ordering fee. Documentation of the circumstances, actions taken, and final resolution will be maintained in the resident record. During weekly medication audits, any resident-provided medications that are awaiting insurance approval, pharmacy fulfillment, practitioner authorization, or other external resolution will be tracked on the Medication Shortage Log to ensure timely follow-up and prevent missed doses whenever possible. MonitoringThe HWD or designee will complete weekly audits of:10% of resident medication records;Medication reorder documentation;Pharmacy refill reports; andMedication shortage logsfor four consecutive weeks. Following successful completion of the weekly audits, monthly audits will be conducted for three months. Audit results will be reviewed during the QMP meeting. Any identified concerns will result in immediate corrective action, staff coaching, and additional monitoring as necessary. Date of ComplianceThe community will achieve compliance on or before 6/5/2026Responsible PersonsHealth and Wellness Director, Registered Nurse, Qualified Medication Administration Personnel (QMAPs), Resident Care Coordinators, and Administrator.

Resident #4's care plan was immediately reviewed and updated to include detailed interventions related to skin-picking behaviors. The care plan now specifies staff responsibilities including redirection when observed picking, application of lotion during hygiene care, monitoring for skin integrity concerns, and application of protective coverings as ordered or recommended by the external healthcare provider. Residents #7 and #17's care plans were reviewed and revised to include all identified personal service needs, resident-specific interventions, and staff responsibilities necessary to meet those needs. Identification of Other Residents Who May Be AffectedThe Health and Wellness Director (HWD), Memory Care Coordinator (MCC), Assisted Living Coordinator (ALC), and Administrator completed a comprehensive audit of all resident care plans within the community to ensure identified needs, behaviors, conditions, preferences, and interventions were accurately reflected in the care plan with clearly defined staff tasks. Any deficiencies identified during the audit were corrected immediately. Measures Put Into Place to Prevent RecurrenceThe community has implemented the following corrective measures:Following any significant change in condition, new behavior, new intervention, physician recommendation, external healthcare provider recommendation, incident trend, or care conference, the resident care plan will be reviewed and updated within seven calendar days. The Assisted Living Coordinator, the Memory Care Coordinator, and the Health and Wellness Director will review all newly identified resident needs during weekly clinical meetings to verify appropriate care plan updates have been completed. The Health and Wellness Director will provide education to the care leadership team, including Resident Care Coordinators and the Memory Care Coordinator, regarding regulatory requirements for resident care plans, emphasizing the requirement that care plans contain resident-specific needs and clearly defined staff interventions and tasks. MonitoringThe Health and Wellness Director or designee will conduct weekly audits of five resident care plans for four consecutive weeks to verify that identified resident needs and corresponding staff interventions are accurately reflected in the care plans. Following successful completion of the weekly audits, monthly audits of ten resident care plans will be conducted for three months. Audit results will be reviewed during the community QMP meetings. Any identified deficiencies will result in immediate correction, staff re-education, and additional monitoring as necessary. Date of ComplianceThe community will achieve compliance on or before 6/12/2026Responsible PersonHealth and Wellness Director, Assisted Living Coordinator, Memory Care Coordinator, and Administrator.

Upon identification of the deficiency, the Health and Wellness Director (HWD) immediately reviewed the medication records and physician orders for Residents #4, #5, #8, #9, #10, #17, and Former Resident #19. For Resident #9, all medications identified as unavailable due to pending delivery were reviewed with the prescribing practitioner and pharmacy. Orders were reconciled, medications were obtained, and administration resumed according to practitioner orders. The HWD completed a clinical review for each affected resident to determine whether any adverse outcomes occurred as a result of missed medications. Practitioner notification and resident monitoring were completed as indicated. Identification of Other Residents Who May Be AffectedThe HWD and care leadership team completed an audit of all current resident medication orders, medication carts, emergency medication supplies, pharmacy refill reports, and medication administration records to identify any medications that were unavailable, pending delivery, or at risk of being missed. Any discrepancies identified during the audit were corrected immediately through physician notification, pharmacy coordination, medication reordering, and staff follow-up. Measures Put Into Place to Prevent RecurrenceThe community has implemented the following system changes:Reeducation has been provided to all QMAPS regarding unavailable medication- QMAPs to verify medication availability during every medication pass and immediately report medications with fewer than seven days remaining. A weekly medication inventory audit will be completed by care leadership or designee to identify medications requiring refill and ensure adequate medication supply is maintained. The HWD, nurse, or designee will review pharmacy refill exception reports, pending deliveries, and medications awaiting authorization a minimum of three times per week. If a medication is unavailable, staff must immediately notify the MCC, ALC or nurse and document the reason for non-administration and contact the pharmacy. A Medication Shortage Log will be used during weekly medication audits to document:Medication nameResident nameDate shortage identifiedPharmacy contactedPractitioner notificationResolution dateFollow-up actions takenAll QMAPs will receive re-education regarding:Medication ordering responsibilitiesRefill proceduresDocumentation requirementsPractitioner order compliance requirements under Chapter 7, Part 14.21Escalation procedures when medications are unavailableCare leadership team will provide re-education to any resident/POA who provides their own medication. Education will include verbiage from our contract indicating:If you procure your own medication through an alternate pharmacy, and such medication will not be delivered to the Community by the time it needs to be administered to you to manage your medical condition, you agree that we may obtain that medication through our contracted pharmacy and you will be responsible for paying our contracted pharmacy for that medication. Golden Pond will assess a $250.00 medication order fee, per medication, per occurrence in addition to the cost of the medication. Care leadership will review any circumstance in which a resident-provided medication is unavailable due to factors outside of the resident's or responsible party's control, including but not limited to insurance authorization delays, pharmacy supply shortages, manufacturer backorders, shipping delays, prescribing practitioner delays, or other unforeseen circumstances. In these situations, the community will work collaboratively with the resident, responsible party, prescribing practitioner, and pharmacy to obtain the medication as quickly as possible and ensure continuity of care. The community will evaluate each situation on a case-by-case basis before assessing any medication ordering fees. If the medication unavailability is determined to be outside the control of the resident or responsible party, the Administrator or Health and Wellness Director may waive the medication ordering fee. Documentation of the circumstances, actions taken, and final resolution will be maintained in the resident record. During weekly medication audits, any resident-provided medications that are awaiting insurance approval, pharmacy fulfillment, practitioner authorization, or other external resolution will be tracked on the Medication Shortage Log to ensure timely follow-up and prevent missed doses whenever possible. MonitoringThe HWD or designee will complete weekly audits of:10% of resident medication records;Medication reorder documentation;Pharmacy refill reports; andMedication shortage logsfor four consecutive weeks. Following successful completion of the weekly audits, monthly audits will be conducted for three months. Audit results will be reviewed during the QMP meeting. Any identified concerns will result in immediate corrective action, staff coaching, and additional monitoring as necessary. Date of ComplianceThe community will achieve compliance on or before 6/5/2026Responsible PersonsHealth and Wellness Director, Registered Nurse, Qualified Medication Administration Personnel (QMAPs), Resident Care Coordinators, and Administrator.

Upon identification of the deficiency, the Health and Wellness Director (HWD) completed Secure Environment Re-Assessments for Residents #8 and #16. The reassessments included:Review of service documentation dating back to the most recent comprehensive assessment;Consultation with the resident's attending practitioner;Consultation with the resident's family and/or resident representative; andDocumentation supporting the resident's continued need for a secure environment. The reassessments were placed in the residents' records and care plans were updated as appropriate. Identification of Other Residents Who May Be AffectedThe HWD, Memory Care Coordinator, and Administrator completed an audit of all residents residing within the Secure Environment to verify:A current Secure Environment Assessment was present;Reassessments had been completed at least every six months;Practitioner consultation was documented;Family and/or resident representative consultation was documented; andService documentation had been reviewed to support continued placement. Any missing or overdue reassessments identified during the audit were completed immediately. Measures Put Into Place to Prevent RecurrenceThe residence has implemented the following corrective measures:A Secure Environment Re-Assessment Form has been implemented requiring documentation of:Practitioner consultation;Family and/or resident representative consultation;Review of service documentation since the last assessment;Clinical rationale supporting continued need for secure placement; andDetermination regarding continued appropriateness of placement. A Secure Environment Tracking Log has been established identifying:Resident name;Admission date to the Secure Environment;Date of last reassessment;Date next reassessment is due; andDate practitioner and family consultations were completed. The Health and Wellness Director, Memory Care Coordinator, and Resident Care Coordinators will receive education regarding Chapter 7, Part 25.9 requirements, including the requirement to complete reassessments every six months and whenever a resident experiences a significant change in condition. Secure Environment reassessment due dates will be reviewed during monthly clinical meetings to ensure upcoming reassessments are completed before becoming overdue. The residence has developed and implemented a new Secure Placement Provider Review Form to ensure compliance with secure environment reassessment requirements. Every six months, and whenever there is a significant change in a resident's condition from baseline, the Health and Wellness Director or designee will complete the form in consultation with:The resident's attending practitioner; andThe resident's family and/or resident representative (documented on theThe form will document:The resident's current cognitive and functional status;Review of relevant service documentation since the previous reassessment;The practitioner's recommendation regarding continued need for secure placement;The determination regarding continued appropriateness of secure environment placement; andAny changes to the resident's care plan or services. Both the attending practitioner will sign the Secure Placement Provider Review Form. The family will sign the quarterly care conference form. The completed forms will be uploaded and maintained within the resident's electronic record in Yardi and will serve as documentation of the required six-month reassessment process. The Secure Placement Tracking Log will include due dates for the Secure Placement Provider Review Form to ensure reviews are completed timely and do not exceed the six-month reassessment requirement. MonitoringThe Administrator or designee will conduct monthly audits of all residents residing within the Secure Environment for three consecutive months to verify:Reassessments are completed timely;Practitioner consultations are documented;Family and/or resident representative consultations are documented;Supporting documentation has been reviewed; andContinued need for secure placement is clearly documented. Audit findings will be reviewed during the community's quality management program (QMP) meetings. Any identified deficiencies will result in immediate corrective action, staff re-education, and additional monitoring as necessary. Date of ComplianceThe community will achieve compliance on or before 6/12/2026Responsible PersonsAdministrator, Health and Wellness Director, Memory Care Coordinator, and Resident Care Coordinators.

Resident #4's care plan was immediately reviewed and updated to include detailed interventions related to skin-picking behaviors. The care plan now specifies staff responsibilities including redirection when observed picking, application of lotion during hygiene care, monitoring for skin integrity concerns, and application of protective coverings as ordered or recommended by the external healthcare provider. Residents #7 and #17's care plans were reviewed and revised to include all identified personal service needs, resident-specific interventions, and staff responsibilities necessary to meet those needs. Identification of Other Residents Who May Be AffectedThe Health and Wellness Director (HWD), Memory Care Coordinator (MCC), Assisted Living Coordinator (ALC), and Administrator completed a comprehensive audit of all resident care plans within the community to ensure identified needs, behaviors, conditions, preferences, and interventions were accurately reflected in the care plan with clearly defined staff tasks. Any deficiencies identified during the audit were corrected immediately. Measures Put Into Place to Prevent RecurrenceThe community has implemented the following corrective measures:Following any significant change in condition, new behavior, new intervention, physician recommendation, external healthcare provider recommendation, incident trend, or care conference, the resident care plan will be reviewed and updated within seven calendar days. The Assisted Living Coordinator, the Memory Care Coordinator, and the Health and Wellness Director will review all newly identified resident needs during weekly clinical meetings to verify appropriate care plan updates have been completed. The Health and Wellness Director will provide education to the care leadership team, including Resident Care Coordinators and the Memory Care Coordinator, regarding regulatory requirements for resident care plans, emphasizing the requirement that care plans contain resident-specific needs and clearly defined staff interventions and tasks. MonitoringThe Health and Wellness Director or designee will conduct weekly audits of five resident care plans for four consecutive weeks to verify that identified resident needs and corresponding staff interventions are accurately reflected in the care plans. Following successful completion of the weekly audits, monthly audits of ten resident care plans will be conducted for three months. Audit results will be reviewed during the community QMP meetings. Any identified deficiencies will result in immediate correction, staff re-education, and additional monitoring as necessary. Date of ComplianceThe community will achieve compliance on or before 6/12/2026Responsible PersonHealth and Wellness Director, Assisted Living Coordinator, Memory Care Coordinator, and Administrator.

Corrective Actions:Immediate Staff Compliance (Completion of Training)Staff #1 and any other direct-care staff members missing dementia training will complete the required training within 10 days of this Plan of Correction submission. Training records will be updated and maintained in personnel files. Review & Audit of Training ComplianceA full audit of all direct-care staff personnel files will be conducted by the Staffing Manager and Executive Director within 30 days. Any staff found missing required dementia training will be scheduled for immediate completion. Training Implementation & Tracking SystemAll training records will be logged in Relias and Paylocity. Staff will receive automated alerts from Relias with any training due within 30 days. The staffing manager will pull the dementia training report weekly and email any staff who have it due or coming due. Policy Revision & EnforcementThe Assisted Living Training Policy will be revised to include:Mandatory completion of dementia training within the first 30 days of employment for direct-care staff. Regular training compliance audits (quarterly) by the Administrator or Designee. Any staff failing to complete dementia training within the required timeframe will be subject to progressive disciplinary action, up to and including suspension. Ongoing Monitoring & Quality AssuranceA quarterly training compliance review will be included in the Quality Management Plan (QMP). A Training Compliance Report will be reviewed by the Executive Director during leadership meetings. Completion Date & Responsible PartyCompletion Date for any staff overdue for dementia training- 10 days from the POC submissionResponsible Party: Staffing Manager and Executive Director Prevention of Future DeficienciesNew hire training process will be modified to ensure dementia training is completed before any direct-care duties begin. A designated training coordinator, Holly Eames, will oversee compliance and ensure all training records are complete.

(Cross-reference S1194, S2512)Corrective Actions:1. Immediate Resident Care Plan UpdatesResident #3 and Resident #8 care plans will be immediately updated to include specific, individualized fall prevention interventions tailored to their needs. Updates will include:Identified risk factors (e.g., balance issues, cognitive impairment, previous fall history, medication side effects). Personalized interventions (e.g., PT/OT referrals, scheduled bathroom assistance, motion sensor alarms, hip protectors, lowering bed height, non-slip socks, or increased supervision). Follow-up assessment completed within 7 days for residents who have 2 or more falls within 30 days. 2. Comprehensive Fall Risk AuditA full audit of all current resident care plans will be conducted within 90 days to ensure compliance with individualized fall interventions. All residents with fall history in the past 90 days will have their care plans reviewed and updated accordingly. A report of falls can be pulled in Yardi EHR.3. Staff Training on Individualized Care PlansMandatory re-education for all staff on individualized care planning and fall risk management. This will happen during the next all-staff meeting. Training will cover:How to document specific interventions instead of generic language like "personalized interventions."How to monitor effectiveness and adjust interventions as needed. Incident reporting and post-fall assessment protocols. Proper fall documentation – including action taken, immediate response, and follow-up interventions. How to document ongoing fall prevention efforts in care plans and progress notes. Training will be completed within 14 days, and all new hires will receive training during orientation. 5. Fall Prevention Interventions & Resident EngagementImplement enhanced strength and balance activities as outlined in Part 12.22(C), including and not limited to:Chair yoga, Tai Chi, and structured PT exercises. Walking programs with assistance for high-risk residents. 6. Quality Assurance & MonitoringFall incident tracking and analysis:Weekly Wellness meetings will review all falls and intervention effectiveness. Trends will be analyzed during the Weekly Wellness meeting to adjust processes if needed. Trends will be analyzed using Yardi’s EHR Incident Analysis,.Quarterly audits will ensure:Fall interventions remain current and individualized in all care plans. 7. Accountability & Responsible PartiesCompletion Deadline: 5/22/25Responsible Parties:Director of Health & Wellness – Ensures care plans are updated. Administrator – Oversees compliance with staff training. Prevention of Future DeficienciesCare plan updates will be required within 72 business hours after any fall. Fall prevention training will be integrated into new hire orientation and quarterly refresher courses. Routine environmental safety checks will be incorporated into the Quality Management Plan (QMP).

(Cross-reference S1180)Corrective Actions:Immediate Update to Incident Reporting and DocumentationCurrent Plan: (Effective 2/14/25)Staff will complete an incident report after any fall. DHW will finalize the report and include expected actions to be taken by staff moving forward in the progress notes section. DHW will include detailed specific interventions in the progress notes section. Future Plan: (modify EHR Incident Form) – eta 60 daysThe Incident Report Form will be modified in Yardi EHR to include:A dedicated section for staff to document actions taken following a fall. A section to detail specific interventions put in place to prevent reoccurrence. 2. Re-Education of Staff on Documentation RequirementsMandatory re-education for all staff on individualized care planning and fall risk management. This will happen during the next all-staff meetingHow to document specific interventions instead of generic language like "personalized interventions."How to monitor effectiveness and adjust interventions as needed. Incident reporting and post-fall assessment protocols. Proper fall documentation – including action taken, immediate response, and follow-up interventions. How to document ongoing fall prevention efforts in care plans and progress notes. Training will be completed within 14 days, and all new hires will receive training during orientation. 3. Care Plan Updates for Affected ResidentsCare plans for Residents #2, #3, and #8 will be updated immediately to:Include specific and individualized fall prevention strategies based on fall history. Detail ongoing interventions such as PT/OT referrals, scheduled safety checks, use of mobility aids, or adjustments to environment (e.g., bed height, grab bars, motion sensors). A full audit of care plans for all residents with a history of falls in the past 90 days will be completed within 90 days of 1/27/25.4. Ongoing Fall Prevention and MonitoringFall incident tracking and analysis:Weekly Wellness meetings will review all falls and intervention effectiveness. Trends will be analyzed during the Weekly Wellness meeting to adjust processes if needed. Trends will be analyzed using Yardi’s EHR Incident Analysis,.Quarterly audits will ensure:Fall interventions remain current and individualized in all care plans. 5. Accountability & Responsible PartiesCompletion Deadline: 5/22/25Responsible Parties:Director of Health & Wellness – Ensures care plans are updated. Administrator – Oversees compliance with staff training. Prevention of Future DeficienciesIncident reports will be reviewed within 24 business hours by a supervisor to verify documentation is complete. Incorporation of documentation audits into the Quality Management Plan (QMP) to sustain compliance.

(Cross-Reference S1180)Corrective Action TakenImmediate Response to the Deficiency:On 1/27/25, a comprehensive environmental tour was conducted to assess hazardous conditions. All visible patches of ice and packed snow on walkways, patios, and bridges were addressed with additional de-icing salt and snow removal. High-risk areas were marked with caution signage until conditions were fully mitigated. Implementation of a Walkway Safety Protocol:Daily exterior audits will be conducted by the Executive Director and/or Maintenance Team to verify:Walkways are free of ice and debris. Awnings are free of icicles. Adequate snow and ice removal supplies (salt, snow melt) are stocked. Hazardous areas are clearly marked until addressed. Audit logs will be maintained to track daily inspections and corrective actions. Staff responsible for snow removal will receive retraining on prompt hazard mitigation and maintaining supply levels. Training to be completed by 2/28/25Prevention and Sustainability Measures:Supply Management:A weekly inventory of snow melt and salt will be conducted, ensuring that materials are available for immediate use. Restocking will occur the same day supplies are identified as low. Emergency Response Plan:Additional staffing adjustments will be made during forecasted snow events to ensure walkways are cleared promptly. Monitoring & Ongoing Compliance:The QMP Walkways plan will be followed, with all deficiencies corrected the same day as identified. Compliance will be monitored through daily audits and staff accountability. Resident concerns will be tracked and addressed immediately upon report. Date of Compliance:Full implementation of this plan will be completed and maintained effective immediately, with continuous monitoring throughout the winter season.