Normandel Place, LLC.

“Based on documentation review, record review, and interview, the the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery for two of two employees sampled. Findings include: 1. A review of E2's personnel record revealed evidence of initial training and continued competency training in fall prevention and fall recovery was not available for review. 2. A review of E3's personnel record revealed evidence of initial training in fall prevention and fall recovery was not available for review. 3. In an interview, E1 acknowledged acknowledged E2's and E3's personnel records did not contain evidence of required fall prevention and fall recovery training. This is a repeated deficiency from a compliance inspection conducted on May 18, 2023.”

“Based on documentation review, and interview the manager failed to ensure a caregiver's or assistant caregiver's skills and knowledge were verified and documented before providing physical health services, for one of two caregivers sampled. The deficient practice posed a risk if employees were unable to meet the needs of residents. Findings include: 1. A review of E2's personnel record revealed E2 was hired as a caregiver on October 24, 2022. Evidence indicating E2's skills and knowledge were verified and documented before providing physical health services was unavailable for review. 2. A review of the facility's policies and procedures, updated March 2024, revealed a policy titled, "Caregiver Job Descriptions, Duties and Qualifications." The policy read as follows: "1. Before providing direct care to the residents at this facility, the Manager will ensure that each caregiver will meet the following... d. Demonstrates the qualifications, skills and knowledge required to provide assisted living services...(Please see Skill Verification Checklist completed by caregiver, manager and or trainer)" 3. In an interview, E1 agreed evidence of documentation of verification of E2's skills and knowledge was unavailable for review.”

“Based on record review and interview, the manager failed to ensure a written service plan was updated at least once every three months, for a resident receiving directed care services. Findings include: 1. A review of R2's (admitted 2023) medical record revealed a service plan for directed care services dated January 8, 2024. However, evidence of an updated service plan on or before April 8, 2024, was unavailable for review. 2. In an interview, E1 acknowledged R2's service plan was not updated at least once every three months as required.”

“Based on record review and interview, the manager failed to ensure the service plan for a resident receiving directed care services included documentation of the resident's weight or documentation from a medical practitioner which stated weighing the resident was contraindicated. The deficient practice posed a risk as the facility would not be aware if there was a significant change in R2's weight. Findings include: 1. A review of R2's medical record revealed a service plans dated January 8 2024, which indicated R2 was receiving directed care services. The service plan did not include documentation of R2's weight. 2. Further review of R2's medical record revealed documentation from a medical practitioner which stated weighing R2 was contraindicated was unavailable for review. 3. In an interview, E1 reported R2's service plan was the most recent service plan available. E1 acknowledged R2's service plan did not contain the residents' weight, and R2's medical record did not contain documentation from a medical practitioner indicating weighing R2 was contraindicated.”

“Based on observation and interview, the manager failed to ensure that poisonous or toxic materials were stored in a locked area, separate from medications and inaccessible to residents. Findings include: 1. During a tour of the facility, the Compliance Officer observed no fewer than two ambulatory residents, and the following: A cabinet under the kitchen sink which was equipped with magnetic locks to secure the door, however the locks were not engaged. The Compliance Officer was able to open the cabinet with little effort and observed one spray bottle of "Great Value Cleaner with Bleach," one bottle of "Great Value All purpose Cleaner with Bleach," a can of "Endust Dust," cleaner and a tub of "finish Powerball Dishwasher Detergent" pods; and In a cabinet located under the sink of a common bathroom accessible to visitors and residents, two spray bottles of "Great Value Cleaner with Bleach," a can of "Great Value Disinfectant Spray," and a spray bottle of "Pine-Sol Multi-Surface Cleaner." 2. In an interview, E1 acknowledged acknowledged the poisonous and toxic materials were not kept in a locked area, inaccessible to residents. This is a repeated deficiency from a compliance inspection conducted on May 18, 2023.”