Golden Swan Manor

Based on documentation review, record review, and interview, the manager failed to ensure a manager and a caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification specific to adults before providing assisted living services to a resident, for two of four sampled personnel. The deficient practice posed a risk if a manager or a caregiver was unable to meet a resident's needs during an emergency. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "Cardiopulmonary Resuscitation and First aid training" which stated: "All managers/ caregivers providing care to residents in the care home must be trained and have a current CPR/ FA card specific to adults... The CPR/ FA card needs to be reviewed every two years." The review further revealed a series of personnel schedules which indicated E1 and E5 worked several shifts per week between February 28, 2024, and April 26, 2024. 2. A review of E1's personnel record revealed E1 was hired as the manager. The review revealed a photocopy of E1's first aid training and CPR training certification dated as expired on February 28, 2024, as well as a printout of E1's current first aid training and CPR training certification dated as issued on April 26, 2024. However, the review revealed E1 did not have current first aid training and CPR training certification for approximately two months. 3. A review of E5's personnel record revealed E5 was hired as a caregiver. The review revealed a photocopy of E5's first aid training certification dated as expired on February 28, 2024, as well as a printout of E5's current first aid training certification dated as issued on April 26, 2024. However, the review revealed E5 did not have current first aid training certification for approximately two months. 4. In an interview, E3 and E4 acknowledged E1 and E5 did not provide current documentation of first aid training and CPR training certification specific to adults before providing assisted living services to a resident. E4 reported E4 had not noticed E1's certification had expired. E4 stated the certifications for E1 and E5 were "two months late."

Based on documentation review, observation, and interview, the manager failed to ensure a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the egress of a resident from the facility. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. During the environmental inspection of the facility, the Compliance Officer observed a door leading from the kitchen to the outdoors. The Compliance Officer observed the door did not have a control installed but did have an alert installed. However, the alert was set to the "OFF" position and did not sound when the Compliance Officer opened the door. 3. In an interview, E1 acknowledged the alert had been turned off.

Based on observation, and interview, the manager failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a risk as residents' rights were violated. Findings include: 1. In observation, upon arrival at the facility, the Compliance Officer (CO) observed nine residents present with two caregivers. 2. Interviews were conducted with R1, R2 R3, O1, and O2, and the following was reported to the CO regarding caregivers E3, E4, and E5: - "They are not courteous, they are rude, all of them, not mannerly..." - "they put residents down... the little things they do... make them feel less than a person, not valuable." - "not treated bad, not treated good, one minute they are nice, the next they aren't, get mad for ringing the call bell to go to the bathroom." - "they reprimand the residents" - "they treat residents like they are children, in a scolding tone." - "they are overworked, tired, frustrated sometimes..." - "E5 yelled at a resident who asked for help getting a telephone number for a funeral home for a friend, and said, "I don't get paid to give telephone numbers.. and so what if he died." 3. During an interview, the findings were reviewed with E1, E2, E3, and E4. E1 acknowledged the findings, and said the residents hadn't expressed concerns to E1. E2 reported the caregivers were very nice and kind.

Based on observation and interview, the manager failed to ensure a bathroom which was accessible from a common area contained paper towels in a dispenser or a mechanical hand dryer. The deficient practice posed a potential infection control risk. Findings include: 1. During an environmental inspection, the compliance officer (CO) observed two bathrooms accessible from a common area did not have paper towels available in the bathroom. A guest bathroom provided for the CO had cloth towels hanging, and no paper towels or a mechanical hand dryer. 2. During an interview, the CO provided the findings to E1, E2, and E5, who acknowledged the bathrooms accessible from the common area did not have paper towels in a dispenser or a mechanical hand dryer.

Based on documentation review, record review, and interview, for four of five personnel reviewed, the manager failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk to the physical health and safety of a resident if all staff were not trained on fall prevention and fall recovery. Findings include: 1. In record review, the personnel records for E1, E2, E3 and E4 did not include documentation of training on fall prevention and fall recovery. 2. In documentation review, the facility had a policy, which indicated personnel would be provided training on fall prevention and fall recovery. 3. During an interview, the findings were reviewed with E1 and E7, who acknowledged the personnel had not received training on fall prevention and fall recovery.

Based on documentation review and interview, the manager failed to submit a documented report to the governing authority per the frequency established in the facility's quality management program. The deficient practice posed a risk if the quality management program procedures were not implemented to effectively manage services provided. Findings include: 1. During an interview, E7 reported a quality management report was submitted to the governing authority every six months, per the facility's policy and procedures. 2. In documentation review, the facility's "Quality Management Indicator Report," dated July-December, 2022, was blank, and did not include tracking of incidents or documentation of a report submitted to the governing authority, that included an identification of each concern about the delivery of services related to resident care, and any change made or action taken as a result of the identification of a concern about the delivery of services related to resident care; 3. During an interview, E1 and E7 reported being unable to locate documentation of the incidents that occurred during the time period of July - December, 2022, and acknowledged a documented report was not submitted to the governing authority during this period.

Based on observation, record review, and interview, for one of four managers and caregivers reviewed, the manager failed to ensure a caregiver provided current documentation of first aid (FA) training and cardiopulmonary resuscitation (CPR) training certification specific to adults. Findings include: 1. In observation, E3 was working at the facility during the inspection. 2. In record review, E3's personnel record (hired on October 31, 2020, as a caregiver) included documentation of FA and CPR training which expired on October 9, 2021. The record did not include documentation of a current CPR/FA card. 3. During an interview, the findings were reviewed with E1 and E7, who acknowledged E3's CPR/FA card in the personnel record was expired, and reported E3 had documentation of current CPR/FA certification located off site. No further documentation was provided for review.

Based on observation, documentation review, and interview, the manager failed to ensure policies and procedures were implemented for discarding medication. The deficient practice posed a health and safety risk if medications were not properly disposed of. Findings include: 1. During an environmental inspection with E1, expired medications were observed on site (stored in the medication cabinet), including: - Pain Relief, expired December, 2018 - Antacid Tabs expired April 2023 - Saline spray expired June 2023 - Glycol Polyethylene 3350 expired March 2023 - Immodium (2 tablets) expired May 2018 - Stool Softener expired June 2020 - Fleet enema expired July 2020 - Enema expired 2019 - Laxatives expired September 2018 2. Two Lantus insulin pens were observed in the refrigerator, (for R5, whose residency was terminated). 3. In documentation review, a facility policy titled, "Medication Disposal" page 42, documented, ... " ... A manager shall ensure that a resident's medication shall be disposed of according to state and federal regulations and established procedure... Prescription medications must be disposed of when it becomes contaminated or damaged, outdated (i.e., expired) or is discontinued by the resident's Medical practitioner. Depending on the situation, destroy the medication at the Facility or return it to the pharmacy. Check expiration dates for all medications (prescription and over the counter) on a regular basis to ensure that all medications are current. Personnel will use the Prescription Disposal form to document the drug, quantity and method used to dispose of medications and place in the appropriate section of resident's medical record." 4. During an interview, E7 acknowledged the medications were not disposed of in accordance with the facility's policies and procedures.

Based on record review and interview, for one resident reviewed, who had an injury resulting in the need for medical services, the caregiver failed to immediately notify a resident's emergency contact of a resident injury, and need for medical services. The deficient practice posed a risk if a resident sustained an injury, and the resident's emergency contact was not notified. Findings include: 1. In record review, R1's medical record (received personal care services), included documentation O2 was R1's emergency contact. The record included documentation of a report, by O3, of a "CT Head without contrast" for "History: Head Trauma," and a "XR Chest... History: Fall" and an "XR Knee 3 views RT... History: Fall, knee pain... Small right knee joint effusion. No definite fracture is seen... There is soft tissue swelling at the level of the knee, most pronounced medially..." R1's record did not include documentation R1's emergency contact was notified. 2. During an interview, O2 reported being R1's emergency contact. O2 reported [O2] was not informed R1 had an injury, and was transported to the emergency room, until O2 went to visit R1, and found R1 was not at the facility. 3. During an interview, the findings were reviewed with E1 and E7. E1 did not recall R1 was sent to the emergency room following a fall. E1 and E7 reported not being able to find documentation of R1's fall, and acknowledged R1's medical record did not include documentation of the fall incident, and subsequent notification of R1's emergency contact.

Based on interview, and record review, for one of five residents reviewed, the manager failed to ensure when a resident had an incident resulting in the resident needing medical services, a caregiver documented the date and time of the incident, the names of individuals who observed the incident, the actions taken by the caregiver, the individuals notified by the caregiver, and any action taken to prevent the incident from occurring in the future. Findings include: 1. In record review, R1's medical record (received personal care services), included documentation of a report, by O3, of a "CT Head without contrast" for "History: Head Trauma," and a "XR Chest... History: Fall" and an "XR Knee 3 views RT... History: Fall, knee pain... Small right knee joint effusion. No definite fracture is seen... There is soft tissue swelling at the level of the knee, most pronounced medially..." R1's record did not include documentation of an incident occurring with R1, including date and time of the incident, the names of individuals who observed the incident, the actions taken by the caregiver, the individuals notified by the caregiver, and any action taken to prevent the incident from occurring in the future. 2. During an interview, O2 reported being R1's emergency contact. O2 reported [O2] was not informed R1 had an injury, and was transported to the emergency room, until O2 went to visit R1, and found R1 was not at the facility. 3. During an interview, the findings were reviewed with E1 and E7. E1 did not recall R1 was sent to the emergency room, following a fall. E1 and E7 reported not being able to find an incident report about R1's fall, and acknowledged R1's medical record did not include documentation of the date and time of the incident, the names of individuals who observed the incident, the actions taken by the caregiver, the individuals notified by the caregiver, and any action taken to prevent the incident from occurring in the future.