Everett Esf

The facility failed to notify the department in writing within 10 calendar days of a change in administrator.

The facility failed to develop and implement an effective program to meet the safety needs of a resident with frequent, unwitnessed falls, resulting in resident harm and continued risk.

Staff member F failed to complete 12 hours of required continuing education.

Facility failed to ensure staff completed necessary training (CPR/First Aid and Continuing Education) prior to providing care.

Staff member C provided CPR/First Aid training certificate for internet-based activity without record of required hands-on skills development.

Facility failed to ensure food was prepared at safe temperatures; observed undercooked Salisbury steak and lack of temperature logs.

Facility failed to ensure 2 of 4 staff completed TB testing upon employment/starting service.

Facility failed to record alternate entree choices on the menu when the approved menu was modified due to a broken appliance. Facility staff were not aware of the requirement to use a diet manual for residents with prescribed diabetic diets.

The facility failed to provide required 1:1 staffing for 4 residents as stipulated in their individual Service plans, leading to instances where staff were assigned to multiple residents simultaneously.

Facility failed to ensure PCSPs were signed by the resident (or representative) and all required team members for 6 of 7 residents reviewed.

Facility failed to conduct required monthly person-centered service planning team meetings for 3 of 7 residents, and meetings that did occur did not include the residents.

Facility failed to ensure department case managers received copies of resident person-centered service plans (PCSPs) for 6 of 7 residents reviewed.

Facility is unable to provide documentation for the annual forward flow test in accordance with NFPA 25.

Facility cannot provide documentation for the completion of twelve planned and unplanned fire drills in the previous 12 months. Missing drills: 2nd Shift - Quarter 3 and 4; 3rd Shift - Quarter 4. Facility is not using the installed fire alarm system for day and swing shift drills.

The facility failed to provide a safe, sanitary, well-maintained environment for eleven residents; 26 used cigarette butts were found on the ground 12 feet from the front door.