Keystone Commons

EOEA reviewed the Residences records and submitted incident reports from 2022 through the day of the compliance review for evidence that all occurrences of an incident or accident that has or may have a Significant Negative Effect on a Resident’s health, safety or welfare were reported to EOEA within 24 hours after the occurrence of the incident during the period reviewed.

The Residence filed 24 incident reports greater than 24 hours after the occurrence of the incident during the period reviewed.

EOEA reviewed response times of the emergency response system from calendar year 2022 through date to the compliance review to determine Service Coordination requirements.

The Residence is not demonstrating an effective means ensuring reasonable staff response times to Resident requests for assistance for all years reviewed.

In the months of November 2022, July 2023 and February 2024, there were 300 e-call response times over the reasonable response time as required by the Residence policy.

EOEA reviewed documentation to ensure the Residence has established an effective, ongoing quality improvement and assurance program for Service Planning, Resident Safety Assurances and Medication Quality for calendar years 2022 and 2023.

Documentation that the Residence provided the date audit conducted and person who conducted each audit was missing for calendar years 2022 and 2023.

Resident Safety Assurances

Documentation that the Residence provided the date audit conducted and staff responsible for follow-up, target date for follow-up, and documented outcome for calendar years 2022 and 2023.

Documentation of monitoring the effectiveness of the Evidence Informed Falls Prevention Program as part of the Resident annual safety review process was missing for calendar years 2022 and 2022.

EOEA reviewed the Residence’s quarterly medication documentation audits for the calendar years 2022 and 2023 through the date of Compliance Review to ensure compliance with SAMM protocols and Residences policies.

The Residence was missing documentation of follow- up action for the clear findings, follow-up action for set target date, staff responsible for follow-up and documented outcome for calendar years 2022 and 2023.

EOEA observed two Care Manager staff providing medication assistance to four Residents and one Nurse staff providing medication assistance to two Residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM and LMA:

SAMM:

One Resident’s Family filled medication cassettes were not labeled with the Resident’s name, room number and dates.

LMA:

One Nurse was observed pre-signing Medication Administration Record sheet prior to administering the medication to the residents.

EOEA reviewed eleven1) Resident Records to determine compliance with requirements for the Screening and Assessment, Service Plan Development and Service Plan Requirements.

Four records were missing documentation of a Service Plan reassessment required within 30-days after the commencement of residency.

EOEA reviewed the current 90-day Correspondence Logs, required to communicate information necessary to maintain the continuity of care for all Residents.

The Residence did not consistently document for both the Traditional and Special Care Residence’s correspondence logs were missing information necessary during each 24-hour period for the continuity of care for Residents.

EOEA reviewed the records of five Residents to determine compliance with the requirements that a nurse review the Resident’s service plan with all relevant personal care workers.

Two records were without documentation to support that Introductory Visits were consistently conducted by a nurse.

EOEA reviewed the Special Care Residence (SCR) operations review from calendar year 2022 through the date of the Compliance Review to verify that the SCR is being administered with all the required safeguards:

Documentation to support the required SCR operations review was incomplete for the second quarter of 2022 and 2023 calendar years reviewed.

EOEA reviewed the Special Care Unit. All Special Care Residences shall be administered in accordance with the following safeguards: 1. The Residence shall develop and implement policies and procedures to assess and reduce the risk of potential hazards in the physical environment related to the special characteristics of the population. Such policies and procedures must include an annual written statement describing in detail how the physical characteristics of any Special Care Residence have been or will be modified to promote the safety of its Residents.

EOEA observed the two Special Care Units:

One Special Care Unit, EOEA noted the windows were easily manipulated to open to the full extent with the unsecure pop-up window blockers located in the common areas and resident’s rooms, the resident rooms also have unsecured doors which lead to an unsecured private outside patio within the Special Care Residence at the time of the Compliance Review.