Normandel Place, LLC

Based on documentation review, record review, and interview, the the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery for two of two employees sampled. Findings include: 1. A review of E2's personnel record revealed evidence of initial training and continued competency training in fall prevention and fall recovery was not available for review. 2. A review of E3's personnel record revealed evidence of initial training in fall prevention and fall recovery was not available for review. 3. In an interview, E1 acknowledged acknowledged E2's and E3's personnel records did not contain evidence of required fall prevention and fall recovery training. This is a repeated deficiency from a compliance inspection conducted on May 18, 2023.

Based on documentation review, and interview the manager failed to ensure a caregiver's or assistant 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 employees were unable to meet the needs of residents. Findings include: 1. A review of E2's personnel record revealed E2 was hired as a caregiver on October 24, 2022. Evidence indicating E2's skills and knowledge were verified and documented before providing physical health services was unavailable for review. 2. A review of the facility's policies and procedures, updated March 2024, revealed a policy titled, "Caregiver Job Descriptions, Duties and Qualifications." The policy read as follows: "1. Before providing direct care to the residents at this facility, the Manager will ensure that each caregiver will meet the following... d. Demonstrates the qualifications, skills and knowledge required to provide assisted living services...(Please see Skill Verification Checklist completed by caregiver, manager and or trainer)" 3. In an interview, E1 agreed evidence of documentation of verification of E2's skills and knowledge was unavailable for review.

Based on record review and interview, the manager failed to ensure a written service plan was updated at least once every three months, for a resident receiving directed care services. Findings include: 1. A review of R2's (admitted 2023) medical record revealed a service plan for directed care services dated January 8, 2024. However, evidence of an updated service plan on or before April 8, 2024, was unavailable for review. 2. In an interview, E1 acknowledged R2's service plan was not updated at least once every three months as required.

Based on record review and interview, the manager failed to ensure the service plan for a resident receiving directed care services included documentation of the resident's weight or documentation from a medical practitioner which stated weighing the resident was contraindicated. The deficient practice posed a risk as the facility would not be aware if there was a significant change in R2's weight. Findings include: 1. A review of R2's medical record revealed a service plans dated January 8 2024, which indicated R2 was receiving directed care services. The service plan did not include documentation of R2's weight. 2. Further review of R2's medical record revealed documentation from a medical practitioner which stated weighing R2 was contraindicated was unavailable for review. 3. In an interview, E1 reported R2's service plan was the most recent service plan available. E1 acknowledged R2's service plan did not contain the residents' weight, and R2's medical record did not contain documentation from a medical practitioner indicating weighing R2 was contraindicated.

Based on observation and interview, the manager failed to ensure that poisonous or toxic materials were stored in a locked area, separate from medications and inaccessible to residents. Findings include: 1. During a tour of the facility, the Compliance Officer observed no fewer than two ambulatory residents, and the following: A cabinet under the kitchen sink which was equipped with magnetic locks to secure the door, however the locks were not engaged. The Compliance Officer was able to open the cabinet with little effort and observed one spray bottle of "Great Value Cleaner with Bleach," one bottle of "Great Value All purpose Cleaner with Bleach," a can of "Endust Dust," cleaner and a tub of "finish Powerball Dishwasher Detergent" pods; and In a cabinet located under the sink of a common bathroom accessible to visitors and residents, two spray bottles of "Great Value Cleaner with Bleach," a can of "Great Value Disinfectant Spray," and a spray bottle of "Pine-Sol Multi-Surface Cleaner." 2. In an interview, E1 acknowledged acknowledged the poisonous and toxic materials were not kept in a locked area, inaccessible to residents. This is a repeated deficiency from a compliance inspection conducted on May 18, 2023.

Based on documentation review, record review, and interview, the the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery. Findings include: 1. A review of facility documentation revealed a training program for fall prevention and fall recovery, however the program did not include continued competency training in fall prevention and fall recovery for employees. 2. A review of E3's personnel record revealed evidence of initial training and continued competency training in fall prevention and fall recovery was not available for review. 3. A review of E4's personnel record revealed evidence of initial training in fall prevention and fall recovery was not available for review. 4. In an interview, E1 acknowledged the fall prevention and fall recovery program had been developed, however did not included continued competency training. E1 also acknowledged E3's and E4's personnel records did not contain evidence of required fall prevention and fall recovery training.

Based on observation, record review, documentation review, and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's completed orientation and inservice education required by policies and procedures, for two of two personnel sampled. The deficient practice posed a risk if the caregivers were unable to meet a resident's needs. Findings include: R9-10-101.155. "Orientation" means the initial instruction and information provided to an individual before the individual starts work or volunteer services in a health care institution. 1. During a tour of the facility the Compliance Officer observed both E3 and E4 to be the only two caregivers working and providing assisted living services at the facility. 2. A review of E3's personnel record revealed E3 was hired as a caregiver in August 2021. However, evidence of documentation of E3's completed inservice education between May 2022 and May 2023 was not available for review. 3. A review of E4's personnel record revealed E4 was hired as an assistant caregiver in February 2023. However, evidence of documentation of E4's orientation was not available for review. 4. A documentation review revealed a policy and procedure (last reviewed May 2022) titled, "Caregiver Orientation and Continuing Education." The policy and procedure stated, "At the time of hire of a new employee the Manager or the Manager's Designee will ensure the employee receives...orientation needed." The policy continued, "This documentation will be maintained in the employee's personnel record." The policy further stated, "All caregivers are required to complete at least six hours of continuing education..." 5. In an interview, E1 acknowledged evidence of documentation E3 received continuing education and evidence E4 received orientation as required by policy was not available for review.

Based on record review and interview, the manager failed to ensure a resident had a written service plan completed no later than 14 calendar days after the resident's date of acceptance, for one of three residents sampled. Findings include: 1. A review of R2's medical record revealed no service plan was available for review. Based on R2's date of acceptance, May 1, 2023, a completed service plan was required. 2. In an interview, E1 acknowledged a service plan was not provided for review. E1 reported the service plan "was not completed".

Based upon record review and interview, the manager failed to ensure a resident has a written service plan which is updated based on changes in the requirements of subsections (A)(3)(a) through (f), at least every six months for a resident receiving personal care services. Findings include: 1. A review of R1's (date of admission October 20, 2022) service plan, revealed R1 received Personal Care services. The service plan was dated October 30, 2022. However, evidence of an updated service plan six months after the initial service plan was unavailable for review. 2. In an interview, E1 acknowledged that R1's service plans was not updated as required.

Based on documentation review, observation, and interview, the manager failed to ensure a means of exiting the facility which controls or alerts employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A review of facility documentation revealed the facility was authorized to provide directed care services. 2. The Compliance Officer observed no fewer than two ambulatory residents on premises. 3. On arrival, the Compliance Officer observed a steel security door at the main entrance which was equipped with a thumbturn deadbolt lock, however the deadbolt was not engaged. The security door was not equipped with a means to alert employees of egress. The Compliance Officer also observed the front door of the facility was equipped with a locking knob. The knob required a key to be used on the inside of the door in order to lock and unlock the knob. The front door was also equipped with an electronic chime to alert employees of any egress from the facility. However, the front door was unlocked and the electronic door chime did not sound when the door was opened by the caregiver. 4. In an interview, E1 acknowledged the door chime for the front door had been turned off and E1 immediately activated the door chime.

Based on observation and interview, the manager failed to ensure that poisonous or toxic materials were stored in a locked area, separate from medications and inaccessible to residents. Findings include: 1. During a tour of the facility, the Compliance Officer observed no fewer than two ambulatory residents, and the following: A cabinet under the kitchen sink which was equipped with magnetic locks to secure the door, however the locks were not engaged. The Compliance Officer was able to open the cabinet with little effort and observed an open can of "Ajax" cleaner and two bottles of generic all purpose cleaner; and A four drawer filing cabinet, located in a hallway leading to a common bathroom used by residents. The filing cabinet was equipped with a locking mechanism which required a key, however the lock was not engaged. In the bottom drawer of the filing cabinet, the Compliance Officer observed two cans of spray paint, an open bottle of "Mr. Clean multi-surface cleaner," and a plastic bin which contained numerous bottles of nail polish. 2. In an interview, E1 acknowledged acknowledged the poisonous and toxic materials were not kept in a locked area, inaccessible to residents. E1 immediately removed the cleaning chemicals, spray paint, and nail polish.