Towers at Glencroft, the

Based on documentation review, record review, and interview, the manager failed to implement policies and procedures to protect the health and safety of a resident to cover cardiopulmonary resuscitation (CPR) training. The deficient practice posed a risk if E4 was unable to perform CPR and the facility's standards were not followed. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "CPR and First Aid Training" (dated June 13, 2023). The policy stated " ... CPR and First Aid training must include a demonstration of the employee's ability to perform cardiopulmonary resuscitation. CPR and First Aid classes must be specific to adults and form one of the following organizations: 1. American Red Cross, 2. American Heart Association, or 3. National Safety Council." 2. A review of E4's (hired in 2022) personnel record revealed E4 was hired as a caregiver. The personnel record revealed documentation of CPR training from NationalCPRFoundation (issued July 13, 2022). The CPR training stated "Valid for 2 years." 3. A review of the NationalCPRFoundation website (https://www.nationalcprfoundation.com/) revealed courses were conducted online. The NationalCPRFoundation website stated "Help Save Lives Today with Your Online CPR Certification Training!" 4. In an interview, E1 acknowledged E4's CPR training was not in compliance with the facility's policies and procedures.

Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver documented the services provided in the resident's medical record, for two of four current residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1's medical record revealed a service plan for personal care services (dated in July 2023). The service plan stated the following service was to be provided to R1: -"Dressing Assistance: Moderate: Staff to assist with buttons, zippers, clasps, some hands on assistance ... Staff will assist the resident with dressing/undressing and clothing selection. ... 2 Times/Day." 2. A review of R1's medical record revealed an activities of daily living (ADL) sheet for August 2023. However, "Dressing Assistance: Moderate: Staff to assist with buttons, zippers, clasps, some hands on assistance ... Staff will assist the resident with dressing/undressing and clothing selection. ... 2 Times/Day" was not documented as provided on August 9, 2023 at 6:00AM and did not include any charting codes for August 9, 2023 at 6:00AM for dressing assistance. 3. A review of R3's medical record revealed a service plan for personal care services (dated in July 2023). The service plan stated the following service was to be provided to R3: -"Facility to provide physical assistance with toileting task which may include cuing, wiping, cleansing and clothing adjustment. ... Staff to assist with toileting every four hours and per resident request." 4. A review of R3's medical record revealed an ADL sheet for August 2023. However, "Facility to provide physical assistance with toileting task which may include cuing, wiping, cleansing and clothing adjustment. ... Staff to assist with toileting every four hours and per resident request" was not documented as provided on August 10, 2023 at 5:00PM and did not include any charting codes for August 10, 2023 at 5:00PM for toileting assistance. 5. In an interview, E1 acknowledged the aforementioned services were not documented as provided in R1's and R3's medical records.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for two of four current residents sampled who received medication administration. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. A review of R1's medical record revealed a service plan for personal care services (dated in July 2023). The service plan revealed R1 received medication administration. 2. A review of R1's medical record revealed a medication order (dated July 6, 2023) for "Losartan Potassium-HCTZ 100-12.5mg Oral Tablet ... Take 1 Tablet Daily." 3. A review of R1's medical record revealed a medication administration record (MAR) for August 2023. However, "Losartan Potassium" was not documented as administered on the following dates and the following times: -August 2, 2023 at 8:00AM. The MAR also did not include any charting codes for August 2, 2023 at 8:00AM for Losartan Potassium. 4. A review of R2's medical record revealed a service plan for personal care services (dated in March 2023). The service plan revealed R2 received medication administration. 5. A review of R2's medical record revealed a medication order (dated July 20, 2023) for "Methenamine Hipp 1 Gm Tablet ... Give 1 Tablet by Mouth Once A Day." 6. A review of R2's medical record revealed a MAR for August 2023. However, "Methenamine" was not documented as administered on the following dates and the following times: -August 16, 2023 at 11:00AM. The MAR also did not include any charting codes for August 16, 2023 at 11:00AM for Methenamine. 7. In an interview, E1 acknowledged medication administered to R1 and R2 were not documented in R1's and R2's medical records.

Based on documentation review and interview, the manager failed to ensure when a resident had an accident, emergency, or injury resulting in the resident needing medical services, a caregiver or assistant caregiver immediately notified the resident's emergency contact and primary care provider. Findings include: R9-10-101(110) "Immediate" means without delay. 1. A review of facility documentation revealed a document for an incident involving R5 occurring on October 1, 2022 at 7:15PM. The document stated " ... the resident was having a hard time breathing ... the med tech had the resident 8 pm breathing treatment and checked to resident O2 90. The med tech informed the nurse about the situation and was told to call the fire department. The EMTs arrived to check the resident ... the resident agreed to go and was taken to [hospital]." The document documented R5's emergency contact and primary care provider were notified at 8:47PM. 2. A review of facility documentation revealed a document for an incident involving R5 occurring on October 4, 2022 at 1:00PM. The document stated "Resident was complaining of chest pain on [R5's] left side. ... Resident was sent out to [hospital]." The document documented R5's emergency contact and primary care provider were notified at 2:00PM. 3. In an interview, E1 acknowledged a caregiver or assistant caregiver did not immediately notify the resident's emergency contact and primary care provider.

Based on record review and interview, the manager failed to ensure when a resident had an accident, emergency, or injury resulting in the resident needing medical services, a caregiver or assistant caregiver documented the action taken to prevent the accident from occurring in the future. Findings include: 1. A review of facility documentation revealed a document for an incident involving R5 occurring on October 4, 2022 at 1:00PM. The document stated "Resident was complaining of chest pain on [R5's] left side. ... Resident was sent out to [hospital]." The document included the date and time of the accident, emergency, or injury; a description of the accident, emergency, or injury; the actions taken by the caregiver or assistant caregiver; and the individuals notified by the caregiver or assistant caregiver. However, any action taken to prevent the accident, emergency, or injury from occurring in the future was not available for review. 2. In an interview, E1 acknowledged actions taken to prevent the accident, emergency, or injury from occurring in the future were not documented.

Based on observation and interview, the manager failed to ensure oxygen containers were secured in an upright position. The deficient practice posed a potential explosion or leak of a compressed gas. Findings include: 1. The Compliance Officer observed three upright oxygen containers in R4's residential unit. However, the three upright oxygen containers were not secured. 2. In an interview, E1 acknowledged the oxygen containers in R4's residential unit were not secured in an upright position.