Eastmark Carehomes

Based on 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 that included initial training and continued competency training, for two of four personnel sampled. The deficient practice posed a health and safety risk for residents. Findings include: 1. A review of E3's personnel record did not include documentation of Fall Prevention and Fall Recovery training. Given E3's date of hire, this documentation was required. 2. A review of E4's personnel record did not include documentation of Fall Prevention and Fall Recovery training. Given E4's date of hire, this documentation was required. 3. In an exit interview conducted over the phone with E2, the findings were reviewed with E2 and no additional information was provided.

Based on documentation review, record review, and interview, the health care institution failed to implement tuberculosis (TB) infection control activities that included annual training and education related to recognizing the signs and symptoms of TB to individuals employed by the health care institution for two out of four personnel reviewed. The deficient practice posed a risk as the caregiver received no organized instruction or information related to TB surveillance. Findings include: 1. A review of the Centers for Disease Control and Prevention (CDC) website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "All health-care workers (HCWs) should receive training on the prevention, transmission, and symptoms of TB disease that is appropriate to their work responsibilities and setting. Initial training should be provided to all new employees, with annual refresher training thereafter." 2. A review of E3's and E4's personnel records did not include documentation of training and education related to recognizing the signs and symptoms of TB. 3. In an exit interview conducted over the phone with E2, the findings were reviewed with E2, and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure documentation was maintained for at least 12 months after the last date on the documentation of the caregivers and assistant caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was incomplete documentation identifying the staff present each day to ensure the health and safety of residents. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "PERSONNEL REQUIREMENTS (STAFFING)." The policy stated "...C.The Manager shall ensure that a personnel schedule: 1. Indicate the date, scheduled work hours and name of each Employee assigned; 2. Reflects actual work hours..." 2. A review of facility documentation revealed a personnel schedule dated between November 1, 2025, and the date of the inspection. However, the schedule did not include the hours worked by each caregiver and assistant caregiver. 3. In an exit interview conducted over the phone with E2, the findings were reviewed with E2 and no additional information was provided.

Based on record review and interview, the manager failed to ensure a caregiver provided current documentation of first aid and cardiopulmonary resuscitation (CPR) training before providing assisted living services, for one of four caregivers reviewed. The deficient practice posed a risk if a caregiver was unable to meet a resident's needs during an emergency. Findings include: 1. A review of E3's personnel record revealed E3 worked as a caregiver and had a hire date of August 5, 2021. The personnel record revealed a first aid and CPR card with an expiration date of October 2025. There was no other current documentation of first aid and CPR training in E3's record. 2. In an exit interview conducted over the phone with E2, the findings were reviewed with E2 and no additional information was provided.

Based on observation, documentation review, record review, and interview, the manager failed to ensure documentation of medication administration included the name and signature of the individual administering medication for two of two residents sampled. The deficient practice posed a health and safety risk to a resident if the facility did not properly document medication administration for a resident, and the Department was provided false and misleading information. Findings include: 1. Upon arrival, the Compliance Officer observed E3 and E4 working at the facility. 2. In an interview with E3, the Compliance Officer was informed E2 and E5 were out of the country at the time of the inspection. 3. A review of the facility's personnel schedule revealed E5 was not on the schedule for November 14, 2025. 4. A review of R1's and R2's Medication Administration Record (MAR) revealed all medications documented as administered on November 14, 2025 to R1 and R2 were documented using E5's initials. 5. A review of the facility's policies and procedures revealed a policy titled "Documenting by Medication Administration Record (MAR) and Assistance." The policy stated, "The facility shall maintain a daily Medication Administration record (MAR) for each resident who receives assistance with self-administration of medications or medication administration. The MAR is the form on which the caregiver will document that medication has been administered to a resident..." 6. In an exit interview conducted over the phone with E2, the findings were reviewed with E2, and no additional information was provided.

Based on observation and interview, the manager failed to ensure toxic materials stored by the facility were stored in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of residents with access to the materials. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed a container of "Kroger Ultra Dish Pacs," in an unlocked cabinet under the sink in the kitchen. 2. In an exit interview conducted over the phone with E2, the findings were reviewed with E2, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a resident had a written service plan to include a description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments, for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan for directed care services dated June 6, 2023. However, the service plan did not include a description of R1's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments. 2. In an interview, E1 acknowledged R1's service plan did not include a description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments.

Based on record review and interview, the manager retained one resident confined to a bed or chair because of an inability to ambulate even with assistance, without a written determination from the resident's primary care or provider or other medical practitioner every six months, stating the resident's needs were met by the facility and the resident's needs were within the facility's scope of services. Findings include: 1. In an interview, E1 reported R2 was non-ambulatory and bed bound. 2. A review of R2's medical record revealed documentation indicating the facility was able to meet the needs of the resident and was signed by a medical practitioner on August 5, 2022. 3. A review of R2's medical record revealed a written service plan for directed care services, dated May 20, 2023. This service plan reported R2 was bed bound. 4. In an interview, E1 reported R2 was unable to ambulate even with assistance. E1 acknowledged a written determination from R2's primary care provider was not completed every six months.