Goldmine Mountain Assisted Living Home

Based on documentation review and interview, the manager failed to ensure policies and procedures were documented to protect the health and safety of a resident that covered methods by which the assisted living facility is aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility is authorized to provide. Findings include: 1. A review of the facility's documentation revealed that the policies and procedures did not cover methods by which the assisted living facility is aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility is authorized to provide. 2. In an interview, E1 acknowledged that the policies and procedures did not cover methods by which the assisted living facility is aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility is authorized to provide.

Based on record review, observation, and interview, the manager failed to ensure a resident had a documented service plan that included, for a resident who would be storing medication in the resident’s bedroom or residential unit, how the medication would be stored and controlled. Findings include: 1. A review of R1's medical record revealed a service plan dated March 7, 2025, which reflected that R1 self-administered medications. R1's service plan did not include how the medication would be stored and controlled. 2 . The compliance officer observed R1's medication to be stored in R1's bedroom, and the compliance officer observed R1's various medications while R1 was in R1's bedroom. 3. In an interview, E1 acknowledged R1 did not have a documented service plan that included how the medication would be stored and controlled in R1's residential bedroom.

Based on record review and interview, the manager failed to ensure assistance in the self-administration of medication provided to a resident was in compliance with an order, and was documented in the resident’s medical record, for one of two sampled residents Findings include: 1. A review of R2's medical record revealed a service plan dated August 1, 2025, which reported R2 received assistance in the self-administration of medication. 2 . A review of R2's medical record revealed a medication order dated August 11, 2025, for Eliquis 5 mg tablet one tablet by mouth twice daily. A review of R2's August 2025 medication administration record (MAR) reported R2 was provided assistance with self-administration of Eliquis 5mg only once per day at 8 pm from August 1, 2025, through August 17, 2025. 3. In an interview, E1 acknowledged that R2's assistance in the self-administration of medication provided to a resident was not in compliance with an order and was documented in the resident’s medical record.

Based on documentation review, and interview the manager failed to ensure a caregiver's skills and knowledge were verified and documented before providing physical health services, for one of two caregivers sampled. The deficient practice posed a risk if E3 was unable to meet the needs of residents. Findings include: 1. A review of E3's personnel record revealed E3 was hired as a caregiver in April 2020. Further review revealed documentation of skills and knowledge training was not available for review. 2. A review of the facility's policies and procedures revealed a document titled "Personnel - Job Descriptions, Duties, and Qualifications," which stated the following: "In the case of a manager or caregiver working in an assisted living facility these skills and responsibilities are documented..." 3. In an interview, E1 acknowledged evidence of documentation of verification of E3's skills and knowledge was unavailable for review.

Based on observation, interview, and record review, the manager failed to ensure a personnel record was established and maintained, for one of three personnel records sampled. The deficient practice posed a risk if O1 was a danger to vulnerable populations. Findings include: 1. The Compliance Officer observed O1 interacting with residents at facility, and going from the kitchen area into the back of the facility, out of sight, where resident bedrooms were located. 2. In an interview, E2 advised O1 was not providing assisted living services, but was a volunteer who helped clean the facility. 3. In an interview, E1 reported O1 was a volunteer who visited residents regularly, but did not provide assisted living services. E1 advised O1 was not an employee, however O1 did do yard work at the facility. E1 agreed O1 was a volunteer at the facility. 4. The Compliance Officer requested to view O1's personnel record, however evidence of O1's personnel record was unavailable for review. 5. In an interview, E1 agreed O1's personnel file was not established.

Based on observation and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. Findings include: 1. Upon entry into the facility, the Compliance Officer observed a medication cart with the locking mechanism out, indicating the medication cart was unlocked. The Compliance Officer was able to open the medication cart drawers. 2. In an interview, E1 acknowledged the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.

Based on documentation review, record review, and interview, the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery, including initial training and continued competency training. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of Department documentation revealed a Plan of Correction (POC) submitted for the compliance inspection conducted July 27, 2022. The POC referenced a training program for all staff regarding fall prevention and fall recovery. The POC Monitoring System stated, "Manager or Administrator shall ensure that fall prevention and fall recovery training and continuous competency shall be provided for all caregivers working in this facility and offered at least once a year. The manager will document, review, update, and file on each employee's file." 2. A review of the facility's policies and procedures revealed a policy regarding fall prevention and fall recovery. However, the policy did not indicate how often the training program was required to be completed by personnel members. 3. A review of E3's personnel record revealed documentation of fall prevention and fall recovery training. However, the training was dated September 9, 2022. 4. A review of E4's personnel record revealed no documentation of fall prevention and fall recovery training. 5. In an interview, E1 acknowledged E3 and E4 did not have current documentation of fall prevention and fall recovery training. This is a repeat deficiency from the compliance inspection conducted July 27, 2022.

Based on documentation review, record review, and interview, the manager failed to ensure policies and procedures were implemented to protect the health and safety of a resident to cover cardiopulmonary resuscitation (CPR) training, including a demonstration of the individual's ability to perform CPR, for one of four personnel sampled. The deficient practice posed a risk to the health and safety of residents as there was no evidence E3 had the ability to perform CPR in an emergency. Findings include: 1. A review of the facility's polices and procedures revealed a policy titled, "Personnel - CPR and First Aid Training." The policy stated "1. Each manager, caregiver, and other applicable employees shall comply with the following: -Obtain CPR training specific to adults which includes a demonstration of the individual's ability to perform CPR. (On-line programs do not meet this requirement unless they include a demonstration of the individual's ability to perform CPR)." 2. A review of E3's personnel record revealed documentation of E3's CPR training from "NewLifeCPR" issued October 14, 2022 and valid for two years. 3. In a telephone interview conducted November 9, 2023, the Compliance Officer called O1 to verify E3's certificate. O1 reported E3 was not listed on the roster of the class that completed training October 14, 2022. In addition, O1 confirmed that O2 was not a trainer with NewLifeCPR.org, but was a trainer for the online-only training class with NewLifeCPR.com. O1 reported O1's company's website was NewLifeCPR.org, not NewLifeCPR.com. 4. In an interview, E1 acknowledged the personnel record for E3 did not include CPR training with hands-on demonstration as required. E1 asked the Compliance Officer how E1 could determine if a training class was online or in-person. The Compliance Officer recommended looking up the company online and/or calling the facility to verify the certificate.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance there was a documented residency agreement with the assisted living facility to include whether the manager or a caregiver is awake during nighttime hours, for two of two residents sampled. The deficient practice posed a risk if the resident was not informed of the terms of residency. Findings include: 1. A review of R1's medical record revealed a residency agreement (dated October 2022). However, the residency agreement did not include whether the manager or a caregiver was awake during nighttime hours. 2. A review of R2's medical record revealed a residency agreement (dated October 2023). However, the residency agreement did not include whether the manager or a caregiver was awake during nighttime hours. 3. In an interview, E1 acknowledged the documented residency agreements for R1 and R2 did not include whether the manager or a caregiver was awake during nighttime hours. Technical assistance was provided regarding this rule during the on-site inspection conducted on July 27, 2022.

Based on record review and interview, the manager failed to ensure a resident's written service plan was reviewed and updated at least once every six months, for one of two sampled residents receiving personal care services. The deficient practice posed a risk if the residents' current needs were not identified. Findings include: 1. A review of R1's medical record revealed a service plan dated April 18, 2023. The service plan indicated R1 received personal care services. There was no documentation of a current service plan for R1. 2. In an interview, E1 acknowledged R1's service plan was not reviewed and updated at least once every six months as required. E1 and E2 were unable to find an updated service plan.

Based on interview and record review, the manager failed to ensure medication administered to a resident was documented in the resident's medical record, for one of two residents sampled receiving medication administration. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. A review of R1's medical record revealed R1 received medication administration. 2. A review of R1's medical record revealed a medication order dated March 22, 2023 for Carvedilol 6.25 milligrams (mg), two times per day with food, hold for SBP less than 100. 3. A review of R1's medication administration record (MAR) revealed R1 received medication administration of Carvedilol two times each day from November 1, 2023 through the morning dose on November 6, 2023. 4. Further review of R1's medical record revealed R1's blood pressure documentation for November 2023. The documentation revealed R1's blood pressure was documented for only November 1, 2023 to November 3, 2023. The documentation revealed R1's blood pressure was not taken on November 4, 2023, November 5, and the morning of November 6, 2023. However, it was documented that R1 received the medication. 5. In an interview, E1 acknowledged medication administration provided to R1 was not documented in R1's medical record as required. E1 reported the caregiver probably wrote R1's blood pressures down in a separate notebook but didn't transfer the readings to R1's medical record.