Glorianne Adult Care Home

Based on documentation review, record review, and interview, the health care institution failed administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not implemented. Findings include: 1. A review of facility documentation revealed a training program to cover fall prevention and fall recovery. The program stated "15. All employees and volunteer upon hire will take part in an in-service training program regarding fall prevention and fall recovery, which will include initial training and continued competency at least every 12 months. Fall prevention training will be documented in the employee or volunteer record." 2. A review of E1's and E2's personnel records revealed a certificate (dated May 31, 2023) titled "Managing Falls of Residents and Caregivers in Residential Facility." However, the training material provided by a third party did not cover fall recovery. 3. In an interview, E1 acknowledged the facility had not implemented the training program to include fall recovery. This is a repeat deficiency from the on-site compliance inspection completed on May 19, 2022.

Based on record review and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan, for one of two residents sampled. The deficient practice posed a risk as a resident did not receive the expected service. Findings include: 1. A review of R1's medical record revealed a current service plan for personal care services dated in May 2023. The service plan revealed R1 was to receive the following service: -"Bathing... Physical assist with bathing twice weekly." 2. A review of R1's medical record revealed an activities of daily living (ADL) log for June 2023 and July 2023. The ADL revealed R1 received "Bathing" on the following dates: - June 1, 2023; - June 7, 2023; - June 15, 2023; - June 23, 2023; and - June 30, 2023. However, documentation to indicate R1 received a bath twice weekly in June 2023 and July 2023 was not available for review. 3. In an interview, E1 reported R1 refused showers because R1 did not want R1's hair washed. E1 reported R1 received partial baths frequently. 4. In an interview, E1 acknowledged R1 had not received baths per R1's service plan.

Based on record review and interview, the manager failed to ensure the service plan for a resident receiving personal care services, included offering sufficient fluids to maintain hydration, for one of one resident sampled who received personal care services. Findings include: 1. A review of R1's medical record revealed a current service plan for personal care services dated in May 2023. However, the service plan did not include offering sufficient fluids to maintain hydration. 2. In an interview, E1 acknowledged R1's service plan for personal care services did not include offering sufficient fluids to maintain hydration.

Based on observation, record review, and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for one of two residents sampled. The deficient practice posed a risk if a resident experienced a change in condition due to improper medication administration. Findings include: 1. The Compliance Officer observed a medication bottle for Senna-Plus tab 8.6-50 mg (take one tablet by mouth two times a day) belonging to R2. 2. A review of R2's medical record revealed a medication list (dated April 2023) signed by a physician. The list included Senna-Docusate (take one tablet daily). 3. A review of R2's medication administration record (MAR) dated July 2023 revealed the following was administered: -Senna-Docusate 5-8.6mg, two tabs daily. 4. A review of R2's medical record revealed a document titled "Diagnosis/Orders" from a hospice agency dated May 3, 2023. The document stated "Start: Senna plus tablet give one tablet by mouth twice a day." However, the document was not signed by a physician. 5. In an interview, E1 reported the medication had been recently changed by hospice. E1 acknowledged R2 had not received medication administration in compliance with a medication order.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A review of facility documentation revealed an evacuation drill for employees and residents was completed on the following dates: - June 18, 2022; and - December 17, 2022. However, an evacuation drill for employees and residents conducted in June of 2023 was not available for review. 2. In an interview, E1 acknowledged an evacuation drill for employees and residents was not conducted at least once every six months.