Pines, the

Based on 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. Findings include: 1. Review of the record for E1 (hired September 2009), failed to reveal documentation of fall prevention and fall recovery training. 2. Review of the record for E2 (hired May 12, 2022), failed to reveal documentation of fall prevention and fall recovery training. 3. Review of the record for E3 (hired October 22, 2018), failed to reveal documentation of fall prevention and fall recovery training. 4. During an interview, E1 indicated that training for fall prevention and fall recovery had not been developed and administered to all staff. This is a repeat deficiency from the compliance inspection conducted on August 4, 2022.

Based on documentation review and interview, the manager failed to submit a documented report to the governing authority per the frequency established in the plan. Findings include: 1. Review of the facility quality management plan revealed that a report was to be submitted to the governing authority on a "yearly" basis. 2. The last report submitted to the governing authority was dated June 30, 2022. 3. During an interview, E1 stated, "I haven't done that report yet."

Based on record review and interview, the manager failed to ensure that one of three sample resident records contained documentation of a written service plan that was reviewed and updated at least once every six months for a resident receiving personal care services. Findings include: 1. The record for R2 contained service plan reviews reflecting the following dates of completion: August 28, 2023 and February 28, 2022. 2. During an interview, E1 acknowledged the service plan documentation did not reflect that the plans were reviewed and updated at least once every six months.

Based on record review and interview the manager failed to ensure that three of three sample resident records contained service plans that when updated, were signed and dated by the resident or resident's representative. Findings include: 1. The record for R1, contained a service plan dated April 9, 2023 that did not contain the dated signature of the resident or the resident's representative. 2. The record for R2, contained a service plan dated August 28, 2023 that did not contain the dated signature of the resident or the resident's representative. 3. The record for R3, contained a service plan dated July 2, 2023 and January 2, 2023 that did not contain the dated signature of the resident or the resident's representative. 4. During an interview, E1 acknowledged that the service plans did not reflect the required dated signature.

Based on record review and interview the manager failed to ensure that three of three sample resident records contained documentation of a written service plan that when updated, was signed and dated by the manager or the manager's designee. Findings include: 1. The record for R1, contained a service plan dated April 9, 2023 that did not contain the dated signature of the manager or the manager's designee. 2. The record for R2, contained a service plan dated August 28, 2023 and February 28, 2022 that did not contain the dated signature of the manager or the manager's designee. 3. The record for R3, contained a service plan dated July 2, 2023 that did not contain the dated signature of the manager or the manager's designee. 4. During an interview, E1 acknowledged that the service plans did not reflect the required dated signature.

Based on record review and interview for one of one sample personal care resident record, the manager failed to obtain documentation reflecting that the resident or resident's representative requested that the resident remain in the facility and a signed and dated statement from a medical practitioner indicating that the resident's needs were being met by the facility as per their scope of services. Findings include: 1. During an interview, E1 indicated that R2 was non-ambulatory, has not walked for more than 30 days and cannot walk even when assisted. 2. The resident's record did not contain a request from the resident or their representative to remain in the facility or a statement from the medical practitioner that the resident's needs were being met as per the facility's scope of services. Based on the resident's date of acceptance this documentation was required. 3. During an interview, E1 acknowledged that the required documentation was not in the resident's record.

Based on documentation review and interview, the manager failed to ensure that a food menu includes food substitution no later than the morning of the day the meal is provided. Finding include: 1. Review of the facility menu for the past two months revealed no changes noted. 2. During an interview, E2 stated "I do make changes to the menu but I haven't been noting it." 3. During an interview, E1 acknowledged that the menu did not reflect food substitutions no later than the morning of the day the food was provided.

Based on documentation review and interview, the manager failed to ensure that the disaster plan was reviewed at least once every 12 months. Findings include: 1. Review of facility documentation failed to reveal that the disaster plan had been reviewed at least once every 12 months. 2. During an interview, E1 acknowledged that the required documentation was not available for review. This is a repeat deficiency from the compliance inspections conducted on August 6, 2021, and August 4, 2022.