New Reflections Adult Care Home

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. Findings include: 1. Review of E2's personnel record revealed documentation E2 completed first aid and cardiopulmonary resuscitation (CPR) training June 23, 2021, with an expiration date of June 23, 2023. 2. In an interview, E2 reported E2 has not completed first aid and cardiopulmonary resuscitation (CPR) training since the identified training completed on June 23, 2021. E2 acknowledged E2's certifications were expired. 3. In an interview, E1 reviewed E2's personnel record and acknowledged E2's first aid and cardiopulmonary resuscitation (CPR) training was expired. E1 acknowledged the manager failed to ensure a caregiver provides current documentation of first aid and cardiopulmonary resuscitation (CPR) training certification.

Based on documentation review, record review, observation, and interview, the manager accepted and retained a resident who were confined to a bed or chair because of an inability to ambulate even with assistance, without a determination from a medical practitioner which stated that the resident's needs could be met by the facility. Findings include: 1. A review of the facility records revealed the facility is licensed for Directed level of care. 2. A review of R2's medical record revealed a personal care service plan completed on May 11, 2023. The service plan identified R2 as "total assist, 2 person and hoyer lift." A review of R2's medical record revealed no documentation of a determination from a medical practitioner that stated R2's needs could be met by the facility due to R2's inability to ambulate even with assistance. 3. In an interview, E1 reviewed R2's medical record. E1 acknowledged R2 was admitted to the facility and identified as non ambulatory. E1 acknowledged R2's medical record did not contain a determination from a medical practitioner which stated that the residents' needs could be met by the facility.

Based on record review and interview, the manager failed to ensure a service plan included documentation of the resident's weight or documentation from a medical practitioner stating weighing the resident was contraindicated for one of two residents reviewed receiving directed care services. Findings include: 1. Review of R1's record revealed a current written service plan for directed care services dated May 1, 2023. This service plan revealed no documentation of R1's weight. A review of R1's record revealed no documentation from a medical practitioner stating weighing R1 was contraindicated. 2. In an interview, E1 reviewed the identified medical record. E1 acknowledged the service plan did not include documentation of the resident's weight. E1 acknowledged additional documentation was not available from a medical practitioner stating weighing the identified resident was contraindicated.

Based on record review, observation, and interview, the manager failed to ensure medication administered to a resident was documented in the resident's medical record. Findings include: 1. A review of R1 and R2's medical records revealed R1 and R2 receive medication administration. 2. A review of R1's medical record revealed signed medication orders for the following medications; Omeprazole 20 mg 1 cap PO, Losartan 50 mg 1 tab PO, Metformin 1000 mg 1 tab BID, and Pramipexole .25 mg 1 tab TID. A review of R1's medical record revealed the identified medications were not documented as administered to R1 on July 31, 2023. 3. A review of R2's medical record revealed signed medication orders for the following medications; Lasix 10 mg 1 tab PO, Lorazepam .5 ml BID, Keppra 100 mg 1 tab BID, Topiramate 50 mg 1 tab BID, Guaifenesin 10 ml 4 x daily, Fluoxetine 20 mg 1 tab PO, and Omeprazole 20 mg 1 tab PO. A review of R2's medical record revealed the identified medications were not documented as administered to R2 on July 31, 2023. 4. The compliance officer observed R1 and R2's medications were available at the facility. 5. In an interview, E2 reported E2 provided medication administration to R1 and R2 at 8 a.m for all of the medications identified. E2 reported E2 did not document the administration of medication for the time identified. 6. In an interview, E1 reviewed R1 and R2's medical record. E1 acknowledged the manager failed to ensure medication administered to a resident was documented in the resident's medical record.

Based on observation and interview, the manager failed to ensure a food menu was prepared at least one week in advance and conspicuously posted at least one calendar day before the first meal on the food menu was served. Findings include: 1. The compliance officer observed a food menu conspicuously posted with the date July 23, 2023 through July 29, 2023. No additional food menu was available for review. 2. In an interview, E1 reported E1 creates the food menu, however E1 had not yet created it for the current week. E1 acknowledged the manager failed to ensure a food menu was prepared at least one week in advance and conspicuously posted at least one calendar day before the first meal on the food menu was served.

Based on documentation review and interview, the manager failed to ensure the facility's disaster plan was reviewed at least once every 12 months. Findings include: 1. A review of the facility's disaster plan revealed the most recent documented review date was December 8, 2021. 2. In an interview, E1 acknowledged the disaster plan was last reviewed on the documented date of December 8, 2021. E1 reported E1 believed E3 reviewed the disaster plan since this date however the review was not documented and available for review. E1 acknowledged the disaster plan was not documented as reviewed at least once every 12 months.

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. Findings include: 1. A review of facility documentation revealed an evacuation drill for employees and residents was completed on June 29, 2022, and March 1, 2023. No additional documentation of evacuation drills for employees and residents conducted at least once every six months was available for review. 2. In an interview, E1, reviewed the evacuation drills. E1 acknowledged no additional drills were available for review. E1 acknowledged evacuation drills for employees and residents were not conducted at least once every six months.