North Central Shores, LLC

Based on documentation review, record review, and interview, for four of eight staff records reviewed, the health care institution failed to 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 policy and procedure covering Fall Prevention. However, the policy and procedures did not include documentation covering Fall Recovery. 2. In record review, the personnel records for E2, E4, E6, E7, and E8 did not include documention the staff received training on fall prevention and fall recovery. 3. During an interview, the findings were reviewed with E1, E9, and E10 who acknowledged the policy and procedures for training personnel on falls did not include training on fall recovery, and the personnel records did not include documentation the personnel received training on fall prevention and fall recovery. This is a repeat deficiency from the complaint investigation and compliance inspection conducted on May 23, 2023.

Based on documentation review, record review, and interview, the manager failed to ensure the facility's incident reporting policy was implemented. The deficient practice posed a risk to a resident, if an incident report was not documented and follow up action taken according to the facility's written policies and procedures. Findings include: 1. In documentation review, the facility's "Quality Management Program including Incident Reports," policy documented, "... Facility personnel will document and evaluate incidents at the facility to ensure quality services are provided. 2. A copy of each filled out form regarding the incident, accident, emergency, unusual occurrence, or event that puts the resident in danger... will be placed in the QOS folder... Caregivers... will immediately report to the manager any change in residents' condition and document observations in the resident's daily Narrative Notes if it's a non-emergency... Caregivers... will report to the manager any incidents that occur while assisting residents... The individual reporting the incident... will complete a "Report of Unusual Occurrence" and follow all instructions and corrective actions specified in the report. 7. The manager designee will immediately report the incident or emergency to the facility manager, and will notify the resident's representative, primary care provider if needed, emergency personnel if needed... The reports of unusual occurrence will be reviewed and signed by the manager... further instructions and corrective criticism will be given to the employee handling the incident, if needed..." 2. In documentation review, the Department received a report R3 had a witnessed fall at the facility, and [R3] hit head and hip on a glass door. 3. During an interview, E1 reported R3 had a fall, which E1 witnessed; however, R3 did not hit [R3's] head on a glass door. 4. In record review, R3's medical record included a narrative note, dated September 27, 2023, "[R3] was walking up ramp to go outside, got off balance by walker getting caught in ramp and fell backwards down ramp onto right side, hitting ... head on the door. [R3] complained of 'R back' and L elbow pain... vitals below..." (Note: no vitals were documented "below"). The resident's record did not include documentation of an incident report or any further documentation of the resident's condition, or follow up by the manager. 5. During an interview, E4 reported E4 observed the resident fall, and documented the narrative note. E4 reported R3 hit [R3's] head during the fall. E1 and E4 acknowledged an incident report, and follow up, was not documented per the facility's policies and procedures.

Based on record review, documentation review, and interview, for one of seven caregivers reviewed, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrator and Assisted Living Facility Managers (NCIA Board). The deficient practice posed a risk if a caregiver was not qualified to provide the required services. Findings include: 1. In record review, E7's personnel record (date of hire August 14, 2023, date of termination September 28, 2023 included a "Certificate," dated "2010," from "Alpha Training, LLC," which documented, "[E7] has completed the training of home health caregiver by aegis Care Advisors PVT Ltd (Care24).' The certificate was not issued by a program approved by the NCIA Board. 2. In documentation review, the facility staffing schedule included documentation E7 worked day and night shifts at the facility, and worked night shifts alone as the only caregiver on duty. 3. During an interview, E1 reported E7 worked at the facility as a caregiver, and covered day and night shifts. E1 acknowledged E7's caregiver certificate was not from an approved program by the NCIA Board, and acknowledged E7 worked as a caregiver without having documentation of completion of a caregiver training program approved by the NCIA Board.

Based on record review, documentation review, and interview, for one of seven caregivers reviewed, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided services. The deficient practice posed a health and safety risk to residents if a caregiver did not have the documented skills and knowledge to provide services for residents. Findings include: 1. In record review, E7's personnel record (date of hire August 14, 2023, date of termination September 28, 2023), did not include documentation the caregiver's skills and knowledge were verified. 2. In documentation review, the facility staffing schedule included documentation E7 worked day and night shifts at the facility, and worked night shifts alone as the only caregiver on duty. 3. During an interview, E1 reported E7 worked at the facility as a caregiver, and covered day and night shifts. E1 reported E7 caused significant problems during employment, and was reported to the police by the facility. E1 reported being unable to locate some of the documents from E7's personnel record, and acknowledged the record provided to the Compliance Officer did not include documentation of the verification of E7's skills and knowledge.

Based on observation, record review and interview, for one of eight managers and caregivers reviewed, the manager failed to ensure a caregiver provided evidence of freedom from infectious tuberculosis (TB). The deficient practice posed a potential health and safety risk of TB exposure to residents and staff. Findings include: 1. In observation, E3 was observed working at the facility on the day of the inspection. 2. In record review, E3's personnel record (hired as a caregiver on February 19, 2024), did not include documentation of freedom from TB, as required. 3. During an interview, E1 acknowledged E3's personnel record did not include documentation of evidence of freedom from infectious TB, as required.

Based on observation, record review, and interview, for one of eight employees reviewed, the manager failed to ensure a personnel record for each employee included documentation of the individual's completed orientation. The deficient practice posed a safety risk to residents if the Department was unable to verify new employees were provided orientation in accordance with the facility's policies and procedures. 1. In record review, E7's personnel record (date of hire August 14, 2023, date of termination September 28, 2023), did not include documentation of E7's completed orientation. 2. In documentation review, the facility staffing schedule included documentation E7 worked day and night shifts at the facility, and worked night shifts alone as the only caregiver on duty. 3. During an interview, E1 reported E7 worked at the facility as a caregiver, and covered day and night shifts. E1 reported E7 caused significant problems during employment, and was reported to the police by the facility. E1 reported being unable to locate some of the documents from E7's personnel record, and acknowledged the record provided to the Compliance Officer did not include documentation of E7's completed orientation.

Based on record review, documentation review, and interview, for one of three residents reviewed, the manager failed to ensure a resident's medical record contained a medication order from a medical practitioner, for each medication that was administered. The deficient practice posed a health and safety risk if the resident received medication without approval from a medical practitioner, and the Department was unable to verify an order for the medication. Findings include: 1. In record review, R3's medical record (received directed care and medication administration services) included documentation R3 received the following medications in December, 2023: Trazadone 200mg, Montelukast 10mg, and Acetaminophen 325 mg. R3's medical record did not include medication orders, signed by a medical practitioner, for these medications. R3's medical record was observed to include documentation of lists of the medications R3 received; however, the medication lists were not signed by the physician or medical practitioner. 2. In documentation review, a facility policy titled, "Medications Including Opioids", documented, "... No medication or treatment is to be administered to the resident without the order and instructions of a physician or medical practitioner. 2. Resident medication regimen and method of administration is reviewed by a medical practitioner to ensure the medication regimen meets the residents needs, when the service plan is completed or when the medication is prescribed..." 3. During an interview, E1 acknowledged R3's medical record did not contain signed medication orders from a medical practitioner, for each medication R3 received.

Based on record review, and interview, for one of three residents reviewed, the manager failed to ensure medications were administered to a resident in compliance with a medication order. The deficient practice posed a health and safety risk to residents, if the facility did not administer medications in compliance with a medication order, and a resident did not receive the required medication. Findings include: 1. In record review, R3's medical record (received directed care and medication administration services) included medication orders for Amlodipine Besylate 5 mg, one tab PO QD, Candesartan 16mg, 1 cap PO QD and Escitalopram 10 mg, one tab PO QD. R3's medication administration records revealed the following: - October 2024; Amlodipine medication not documented as administered on Oct 4-5, 2023. - January 2024; Amlodipine medication not documented as administered at 8:am on January 1 - 3, 2024. - February 2024; No MAR was available for review 2. During an interview, E1 acknowledged R3's medication administration records indicated days when R3 did not receive the medications, as prescribed. E1 reported being unable to locate R3's February MAR. 3. In record review, R3's medical record (received directed care and medication administration services) included documentation R3 received the following medications in December, 2023: Trazadone 200mg, Montelukast 10mg, and Acetaminophen 325 mg. R3's medical record did not include medication orders, signed by a medical practitioner, for these medications. R3's medical record was observed to include documentation of lists of the medications R3 received; however, the medication lists were not signed by the physician or medical practitioner. 4. In documentation review, a facility policy titled, "Medications Including Opioids", documented, "... No medication or treatment is to be administered to the resident without the order and instructions of a physician or medical practitioner. 2. Resident medication regimen and method of administration is reviewed by a medical practitioner to ensure the medication regimen meets the residents needs, when the service plan is completed or when the medication is prescribed..." 5. During an interview, E1 acknowledged R3's medical record did not contain signed medication orders from a medical practitioner, for each medication R3 received.

Based on documentation review, record review, and interview, for four of five personnel reviewed, the manager failed to ensure the health care institution administered 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. Findings include: 1. In documentation review, the facility had documentation of a training program for fall prevention and fall recovery program. 2. In record review, the personnel records for E2, E3, E4, and E5, did not include documentation the personnel received training on fall prevention and fall recovery. 3. During an interview, the findings were reviewed with E1 who reported the personnel had not received training on fall prevention and fall recovery.

Based on record review, and interview, for one of five caregivers reviewed, the manager failed to ensure a caregiver provided documentation of first aid (FA) training specific to adults. The deficient practice posed a health and safety risk to residents if a caregiver did not have FA training. Findings include: 1. In record review, the personnel record for E3 (hired as a caregiver on April 10, 2023), did not include documentation of FA training. 2. In an interview, the findings were reviewed with E1, who reported E3 was hired as a caregiver, and acknowledged E3 did not provide documentation of FA training.

Based on record review, and interview, for two of one of three residents reviewed, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record. The deficient practice posed a health and safety risk to a resident if a manager or caregiver did not know if a medication was administered. Findings include: 1. In record review, R2's medical record included medication orders for Adempas 1.5 mg, 1 tab po tid, Donepezil HCL 10 mg , 1 tab po q hs, Seroquel 25 mg 1 tab po bid, Eliquis 5 mg, 1 tab po bid, and check blood pressure TID and document (for Adempas too). 2. In record review, R2's medication administration, dated May, 2023, revealed no documentation of medication administration as follows: - Seroquel and Eliquis at 5:00pm on May 2, and May 10, 2023 - Adempas at 8:00am and 2:00pm on May 16 - 18, 2023, and at 8:00pm on May 1, 6-10, 16, 17, 21, 22, 2023 - Ketoconazole cream on May 11, 2023 - Donepezil on May 1, 15, 20-22, 2023 - Blood pressure 3 x daily May 18, through May 23, 2023 3. In an interview, the findings were reviewed with E1, who reported the medications were administered by caregivers; however, R2 often refused medications. E1 acknowledged the medication administration and/or refusal of medication by R2 was not documented on the MAR, as noted above.