Serenade Assisted Living, LLC

Based on documentation review, record review, and interview, the manager failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training for three of three personnel sampled. The deficient practice posed a health and safety risk for residents. Findings include: 1. A review of the facility's policies and procedures revealed an policy titled, "Fall prevention awareness and training." The policy stated, "4. Staff must be trained in fall prevention, CPR/First aid, and emergency procedures on a regular basis in training meetings." 2. A review of E1's, E2's, and E3's personnel records revealed no documentation of Fall Prevention and Fall Recovery training. 3. In an interview, E1 acknowledged the facility failed to administer a training program regarding fall prevention and fall recovery that included initial training and continued competency training.

Based on documentation review and interview, the manager failed to ensure that a documented report was submitted to the governing authority that included: an identification of each concern about the delivery of services related to resident care, and any change made or action taken as a result of the identification of a concern about the delivery of services related to resident care. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Quality Management Program." The policy (dated March 8, 2023) stated, "1. All employees must immediately make an oral or written report to the facility manager or manager's designee of any condition, situation, or incident which has, or has the potential to, adversely affect the health and/or safety of one or more residents. ... 4. Every 6 months these forms will be evaluated and the number of incidences in each category tallied on the Quality Management Report to determine trends effecting the care and services provided to residents. 5. The Quality Management Report will be discussed by all employees at a Quality Management meeting held on October 31 and April 30 of each year." 2. A review of the facility's Quality Management Program binder revealed no documentation of the bi-annual quality management report submission required per the facility's policies and procedures. 3. In an interview, E1 acknowledged the quality management report was not submitted per the frequency established in the facility's policies and procedures.

Based on documentation review, record review, and interview, the manager failed to ensure that a personnel record for each employee included documentation of the individual's in-service education required by policies and procedures. The deficient practice posed a risk as the caregiver received no organized instruction or information related to physical health services provided to residents. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Caregiver Orientation, On Going Training and In Service Meetings." The policy stated, "2. Caregiver on going training will be given on as needed basis individually or as a group. 3. Caregiver updates will be given before starting shift each day. 4. Caregiver training meetings will be held on as needed basis or along with disaster and evacuation drills. Attending caregivers will sign the agenda for training meetings which will be kept in the On Going Training Notebook in the office cabinet." 2. A review of the facility's On Going Training Notebook revealed documentation of on going caregiver training dated January 27, 2021. However, no documentation of further training was available for Compliance Officer review. 3. A review of E1's, E2's, and E3's personnel records revealed no documentation of current on going personnel training. 4. In an interview, E1 reported on going trainings were held at the start of each shift and were not documented. E1 acknowledged E1's, E2's, and E3's personnel records did not include documentation of the individual's in-service education required by the facility's policies and procedures.

Based on record review and interview, the manager failed to ensure that a caregiver documented the services provided in the resident's medical record for one of two residents sampled. The deficient practice posed a risk if services provided could not be verified. Findings include: 1. A review of R1's service plan revealed R1 received the following assisted living services: - Shower, twice a week; - Peri care, after each disposable change; - Brush teeth, daily; - Assist dressing, daily; - Comb hair, daily; - Skin care, as needed (PRN); - Foot care, PRN; - Check pressure areas, PRN; - Encouragement to drink fluids; - Incontinence care; and - Changing of disposable undergarments, PRN. 2. A review of R1's activities of daily living (ADL) documentation revealed R1 received the following assisted living services: - Shower, twice a week; - Toileting, PRN; - Clean bathroom, no frequency documented; and - Empty trash, no frequency documented. 3. In an interview, E1 reported R1 had been receiving the services documented in R1's service plan, however documentation of those services provided was not available. E1 acknowledged R1's medical record did not contain documentation of assisted living services provided to the resident.

Based on record review, observation, and interview, the manager failed to ensure that there was a means of exiting the facility that controlled or alerted employees of the egress of a resident from the facility on all exits. 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 R1's medical record revealed R1 received directed care services. 2. During an environmental tour of the facility, the Compliance Officer observed the front door was equipped with an alarm to alert employees of egress; however the alarm was not turned on at the time of inspection. 3. The Compliance Officer did not observe an alarm or other way to control or alert employees of the egress of a resident from the facility on the doors into the backyard both from the kitchen and the back of the house. 4. In an interview, E1 acknowledged that the facility provided directed care services, and did not contain a way to control or alert employees of the egress of a resident from the facility on all exits.

Based on record review and interview, the manager failed to ensure that medication administered to a resident was accurately documented in the resident's medical record for one of two residents sampled. The deficient practice posed a risk as false or misleading information was provided to the Department. Findings include: 1. A review of R1's medical record revealed R1 received medication administration. 2. A review of R1's MAR for September 2024 revealed documentation that Donepezil HCl 10 mg, 1 tablet by mouth was administered on September 3, 2024 at 7:00PM, however MAR documentation was printed and provided for Compliance Officer review at 11:35 AM. 3. In an interview, E1 acknowledged R1's medical record did not contain accurate documentation of medication administered to the resident.

Based on documentation review and interview, the manager failed to ensure the facility's disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. A review of the facility's policies and procedures revealed the facility's disaster plan was reviewed on November 1, 2021. However no documentation of further review was available. 2. In an interview, E1 acknowledged that the facility's disaster plan was not reviewed at least once every 12 months.

Based on observation and interview, the manager failed to ensure that toxic materials stored by the assisted living facility were maintained in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental tour of the facility, the Compliance Officer observed the following hazardous materials stored by the facility in an open container under the counter of the unlocked dishwasher room: - Heavy Duty Degreaser; - The Pink Stuff The Miracle Multi-Purpose Cleaner; - Brillo Soap Pads; and - Pure Bright Germicidal Ultra Bleach. However, there was no way to lock the swinging door into the kitchen, or contain the hazards in the dishwasher room. 2. In an interview, E1 acknowledged the toxic materials stored by the facility were not maintained in a locked area and inaccessible to residents.