Providence Manoir Assisted Living

Based on observation, documentation review, and interview, the manager failed to ensure that a resident’s sleeping area was not used as a passageway to a common area or another sleeping area unless the sleeping area was used as a passageway to another common area before October 1, 2013.  Findings include: 1. During an environmental tour, the Compliance Officer observed a locked walk-in closet in a resident’s bathroom. After further observation, the Compliance Officer observed a mattress on the floor, clothing, and personal items in the closet. 2. A review of the facility’s policies and procedures revealed a policy titled "Physical Plant Standards”. The policy stated, “4. A resident’s sleeping area is not used as a passageway to a common area, another sleeping area, or common bathroom.” 3. A review of department documentation revealed the home was licensed on June 8, 2022. 4. In an interview, E1 reported the room was used as a break room sometimes. 5. In an exit interview, the findings were discussed with E1, and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services, for one of two caregivers sampled. Findings include: 1. A review of facility documentation revealed a staffing schedule dated August 2023. The schedule indicated E2 was scheduled to work at the facility every day in August from 7:00 AM to 7:00 PM. 2. A review of E2's personnel record revealed a document titled "Employee skills and knowledge." However, the document did not indicate E2's skills and knowledge were verified. 3. In an interview, E4 acknowledged the manager failed to ensure E2's skills and knowledge were verified and documented before E2 provided physical health services.

Based on documentation review and interview, the manager failed to ensure policies and procedures for medication administration were reviewed and approved by a medical practitioner, registered nurse, or pharmacist. Findings include: 1. A review of facility documentation revealed a policy and procedure manual, dated May 2022. The manual included several policies and procedures for medication administration, including "Medication Administration Authorization," and "Medication Statement." However, there was no documentation to indicate the policies and procedures were reviewed and approved by a medical practitioner, registered nurse, or pharmacist. 2. In an interview, E4 acknowledged the policies and procedures for medication administration were not reviewed and approved by a medical practitioner, registered nurse, or pharmacist.

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. The deficient practice posed a risk if employees were unable to safely evacuate residents in an emergency. Findings include: 1. A review of facility documentation revealed no documented employee and resident evacuation drills available for review. 2. In an interview, E4 acknowledged documentation was not available showing an evacuation drill for employees and residents was conducted at least once every six months.