Cornerstone AL LLC

Based on documentation review and interview, the manager failed to establish and document policies and procedures to protect the health and safety of a resident to cover qualifications, including required skills and knowledge, for employees and volunteers. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees, the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the licensee did not provided the documentation within two hours after a Department request. Findings include: 1. A review of Department documentation revealed the license for AL11426 was effective March 12, 2020. 2. A review of the facility's policies and procedures revealed a policy titled "a. JOB DESCRIPTIONS, DUTIES, AND QUALIFICATIONS" dated February 22, 2023. The policy stated: "POLICY: The Facility must have Managers, Caregivers, assistant caregivers and volunteers with the qualifications, experience, skills and knowledge necessary to provide the assisted living services, behavioral health services, behavioral care, and ancillary services in the assisted living...Caregivers a. Qualifications i. 18 years of age or older...ii. Caregiver training certificate...iii. Valid fingerprint card....iv. Proof of freedom from TB...v. CPR and First Aid training...vi. Read, write, speak and understand English...b. Duties i. Assist Residents with activities of daily living as required in each Resident's service plan...ii. Supervise of and/or assist in the self-administration of medication as required in each Resident's service plan...iii. Provide supervisory care, personal care, directed care, and behavioral care to Residents as required in each Resident's service plan...iv. Maintain the Facility in clean and safe condition v. Prepare and serve food vi. Document all services provided to Residents in each Resident's record vii. Other duties as assigned." However, the policy did not include the required skills and knowledge for employees and volunteers. 3. In an interview, E1 acknowledged policies and procedures to cover required skills and knowledge for employees and volunteers was not available for review.

Based on documentation review, record review, and interview, the administrator failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "a. JOB DESCRIPTIONS, DUTIES, AND QUALIFICATIONS" dated February 22, 2023. The policy stated "POLICY: The Facility must have Managers, Caregivers, assistant caregivers and volunteers with the qualifications, experience, skills and knowledge necessary to provide the assisted living services, behavioral health services, behavioral care, and ancillary services in the assisted living...Caregivers a. Qualifications i. 18 years of age or older...ii. Caregiver training certificate...iii. Valid fingerprint card....iv. Proof of freedom from TB...v. CPR and First Aid training...vi. Read, write, speak and understand English...b. Duties i. Assist Residents with activities of daily living as required in each Resident's service plan...ii. Supervise of and/or assist in the self-administration of medication as required in each Resident's service plan...iii. Provide supervisory care, personal care, directed care, and behavioral care to Residents as required in each Resident's service plan...iv. Maintain the Facility in clean and safe condition v. Prepare and serve food vi. Document all services provided to Residents in each Resident's record vii. Other duties as assigned." However, the policy did not include the required skills and knowledge for employees and volunteers. 2. A review of E1's personnel record revealed documentation of evidence of E1's qualifications, including skills and knowledge applicable to E1's job duties was not available for review. 3. A review of E2's personnel record revealed documentation of evidence of E2's qualifications, including skills and knowledge applicable to E2's job duties was not available for review. 4. A review of E3's personnel record revealed documentation of evidence of E3's qualifications, including skills and knowledge applicable to E3's job duties was not available for review. 5. A review of E1's personnel record revealed documentation of E1's completed CPR or first aid training from the American Safety Health Institute. The document contained two lines which stated "Class Completion Date...Expiration date." However, the aforementioned lines were left blank. 6. A review of E2's personnel record revealed documentation of E2's completed CPR or first aid training from the American Safety Health Institute. The document contained two lines which stated "Class Completion Date...Expiration date." However, the aforementioned lines were left blank. 7. A review of facility documentation revealed an invoice document for pest control services dated February 22, 2021. The document stated "Power spray service...length of agreement

Based on record review, documentation review, and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's qualifications, including skills and knowledge applicable to the individual's job duties, for three of three personnel members sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs, the Department was unable to determine substantial compliance as the personnel records did not include the documentation during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A review of E1's personnel record revealed documentation of evidence of E1's qualifications, including skills and knowledge applicable to E1's job duties was not available for review. 2. A review of E2's personnel record revealed documentation of evidence of E2's qualifications, including skills and knowledge applicable to E2's job duties was not available for review. 3. A review of E3's personnel record revealed documentation of evidence of E3's qualifications, including skills and knowledge applicable to E3's job duties was not available for review. 4. A review of the facility's policies and procedures revealed a policy titled "a. JOB DESCRIPTIONS, DUTIES, AND QUALIFICATIONS" dated February 22, 2023. The policy stated "POLICY: The Facility must have Managers, Caregivers, assistant caregivers and volunteers with the qualifications, experience, skills and knowledge necessary to provide the assisted living services, behavioral health services, behavioral care, and ancillary services in the assisted living...Caregivers a. Qualifications i. 18 years of age or older...ii. Caregiver training certificate...iii. Valid fingerprint card....iv. Proof of freedom from TB...v. CPR and First Aid training...vi. Read, write, speak and understand English...b. Duties i. Assist Residents with activities of daily living as required in each Resident's service plan...ii. Supervise of and/or assist in the self-administration of medication as required in each Resident's service plan...iii. Provide supervisory care, personal care, directed care, and behavioral care to Residents as required in each Resident's service plan...iv. Maintain the Facility in clean and safe condition v. Prepare and serve food vi. Document all services provided to Residents in each Resident's record vii. Other duties as assigned." However, the policy did not include the required skills and knowledge for employees and volunteers. 5. In an interview, E1 reported E1's, E2's, and E3's skills and knowledge were verified, however, E1 did not document E1's, E2's and E3's skills and knowledge. E1 acknowledged E1's, E2's and E3's personnel record did not include documentation of E1's, E2's, and E3's skills and knowledge, applicable to E1's, E2's and E3's job duties.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of cardiopulmonary resuscitation training (CPR) and first aid training, for two of three caregivers sampled. The deficient practice posed a risk if E1 and E2 were unable to meet a resident's needs, the Department was unable to determine substantial compliance as the personnel record did not include the documentation, and the documentation was not provided to the Department within two hours after a Department request. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "d. CPR AND FIRST AID TRAINING" dated February 22, 2023. The policy stated "POLICY: All Staff who has direct interaction with Residents is required to have CPR training...The manager will be responsible to make sure all Staff has required training and to maintain copies of each Staff member's current CPR and First Aid certifications in their respective records..." 2. A review of E1's personnel record revealed documentation of E1's completed CPR or first aid training from the American Safety Health Institute. The document contained two lines which stated "Class Completion Date...Expiration date." However, the aforementioned lines were left blank. 3. A review of E2's personnel record revealed documentation of E2's completed CPR or first aid training from the American Safety Health Institute. The document contained two lines which stated "Class Completion Date...Expiration date." However, the aforementioned lines were left blank. 4. In an interview, E1 reported the CPR and first aid training for E1 and E2 was current, and O1 forgot to document the completion date. E1 acknowledged E1's and E2's CPR and first aid training was not included in E2's personnel record.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was administered compliance with a medication order, for one of two residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R2's medical record revealed a treatment plan indicating R2 received medication administration. R2's medical record contained a medication order dated May 2, 2023. The medication order revealed the following: -"Advair Diskus 100 mcg (microgram)-50 mcg/dose powder for inhalation inhale one actuation every 12 hours"; and -"Duloxetine 60 mg (milligram) capsule delayed release take one cap PO every day." 2. A review of R2's medical record revealed a medication administration record (MAR) dated May 2023. The MAR revealed "Advair Diskus 100 mcg-50 mcg/dose powder" and "Duloxetine 60 mg capsule" were not documented as administered. 3. The Compliance Officer observed R2's medications, and "Advair Diskus 100 mcg-50 mcg/dose powder" and "Duloxetine 60 mg capsule" were not included or available for review. 4. In an interview, E1 reported R2 was not administered "Advair Diskus 100 mcg-50 mcg/dose powder" and "Duloxetine 60 mg capsule". E1 reported R2's aforementioned medications were being delivered later in the day. E1 acknowledged R2 was not administered medication in compliance with R2's medication orders.

Based on documentation review and interview, the manager failed to ensure a pest control program in compliance with R3-8-201(C)(4) was implemented and documented. The deficient practice posed a risk as the facility standards were not documented, were not available during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A review of Department documentation revealed the license for AL11426 was effective on March 12, 2020. 2. A review of the facility's policies and procedures revealed a policy titled "c. EQUIPMENT INSPECTION AND MAINTENANCE" dated February 22, 2023. The policy stated "PROCEDURE: The Manager shall ensure that:...B. A pest control program is implemented and documented." 3. A review of facility documentation revealed an invoice document for pest control services dated February 22, 2021. The document stated "Power spray service...length of agreement 1 year 3 year 5 year". However, "length of agreement" was crossed out, and documentation of pest control services provided to the facility was not available for review. 4. In an interview, E1 reported a pest control company comes out "once in a while". E1 acknowledged the pest control program was not documented.