Goddard House

• Service and Service Coordination Requirements-

Self-Administered Medication Management (SAMM)

• EOEA reviewed ten (10) Resident Records to determine compliance with requirements for Self-administered Medication Management (SAMM).
• Documentation of actions regarding whether the Resident took or refused the medication on multiple dates and times was missing for two (2) Residents.

Emergency Response

• AGE reviewed the Personalized Emergency Response procedures developed to provide timely assistance to a Resident in the event of an emergency situation.
• The policy developed by the Residence does not specify what constitutes a prompt response and timely assistance to Residents. The Residence management confirmed that the maximum response time is eight (8) minutes.
• During the months of July 2023, April 2024 and January 2025, there were 149 e-call response times over the eight (8) minute limit.
• Documentation of monitoring e-call response times over the eight (8) minute limit was missing for the month of January 2025.
• Service and Service Coordination- Special Care
• AGE reviewed the Special Care Residence (SCR) operations on the date of the Compliance Review to verify that the SCR is complying with all the required safeguards.
• Age identified deficiencies with operational safeguards related to the risk of potential hazards in the physical environment:
• Cleaning supplies were unsecured on both SCR floors.
• Three (3) microwaves were operational without required safeguards to only allow supervised access.
• One (1) laundry door on the second floor was unsecured.
• Three (3) doors to mechanical closets on the second floor were unsecured.
• A tool shed located in the outside area for SCR Residents had an unsecured door.
• General Requirements for an Assisted Living Residence (ALR)-
• AGE reviewed ten (10) Resident Records reviewing documentation from December 2022 through the date of the Compliance Review to determine compliance with the requirements for Screenings, Assessments and Service Plan Development and Requirements.

Screening and Assessment

• Four (4) records were missing documentation of a service plan reassessment required within 30 days after the commencement of residency.
• Two (2) records were missing signatures of the Resident or Legal Representative.

Service Plan Development and Requirements

• Four (4) records were missing documentation of a service plan review required within 30 days after the commencement of residency.
• Documentation of individualized enrichment activities provided to the residents was missing in four (4) Special Care Residence (SCR) records.
• Two (2) records were missing signatures of the Resident or Legal Representative.
• Four (4) Special Care Residence (SCR) records were missing documentation of how the Residence provides 24-hours per day, awake, onsite staff.

Bed Rail Assessments

• AGE reviewed the Residence records of 29 Residents utilizing bed rails / U-bars or similar devices for the period of 2023 through the date of the Compliance Review to determine compliance with the required assessment by a physical/occupational therapist every six months.
• Documentation of an assessment conducted by a physical/occupational therapist every six months for 29 Residents noting that the Resident can independently navigate around a bed rail/ U-bar was missing.
• Quality Assurance and Performance Improvement
• AGE reviewed documentation to ensure the Residence has established an effective, ongoing quality improvement and assurance program for Service Planning, Safety Assurances, and Medication Quality from December 15, 2022, through the date of the Compliance Review.

Service Planning

• Documentation of the date the audit was completed, the person conducting the audit and the audit identifying records by number or code up was missing for the 2023 and 2024 calendar years reviewed.

Resident Safety Assurances

• Documentation of the review date was missing for the 2023 and 2024 reviews.

Medication Quality Plan

• AGE reviewed the Residence's quarterly medication documentation audits from December 15, 2022, through the date of the Compliance Review to ensure compliance with SAMM, LMA and Residence policies.
• Documentation of the date the audit was completed was missing for all four quarters of the 2024 calendar year reviewed.

Medication administration observation

• AGE observed five (5) Personal Care (PC) staff and two (2) nurses providing medication assistance to nine (9) Residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM / LMA.

SAMM

• One (1) Resident's medication storage unit contained a bag full of unidentified loose pills and open medication blister packs, some still containing pills.
• One (1) Resident's SAMM medication storage unit also contained LMA medications.
• Two (2) Resident's family filled medication cassettes were not properly labeled.
• Three (3) Resident's medication storage units contained expired medications.
• Two (2) Resident's medication storage units contained medications that were not on the current medication list.
• Two (2) Resident's medication storage units contained discontinued medications.

LMA

• Two (2) Resident's medication storage units each contained an unidentified loose pill.
• One (1) Resident's medication storage unit contained Exemption C Exemption C without documentation of an open date and a medication that did not have a pharmacy label.
• Two (2) Resident's medication storage units each contained expired medications.
• One (1) Resident's medication storage unit contained discontinued medications.
• Reporting Resident-specific Emergencies- Incident Reports
• AGE reviewed the Residence records and incident reports from December 2022 through the date of the Compliance Review to determine whether the Residence complied with the requirement to report qualifying incidents to AGE within 24 hours after the occurrence of the incident or accident.
• The Residence filed 81 incident reports greater than 24 hours after the occurrence of the incident or accident.
• Record Requirements- Personnel Record Requirements
• EOEA reviewed the personnel records of ten (10) staff members to determine compliance with personnel record requirements.
• Three (3) personnel records were missing documentation of a signed job description.
• Training Requirements-

General Orientation

• EOEA reviewed the personnel records of seven (7) staff members to determine compliance with orientation requirements.
• Documentation of General Orientation for seven (7) staff records was incomplete.

Introductory Visit and Review

• AGE reviewed the records of ten (10) Residents to determine compliance with the requirements that a nurse reviews the Resident's service plan with all relevant personal care workers within the 48 hours after the provision of service or with any change of condition for the Resident:
• Six (6) records were without documentation to support that Introductory Visits were consistently conducted with all applicable staff prior to or within 48 hours, at the time of move-in or at the time of change in the Resident's condition.

Supervision

• AGE reviewed the records of five (5) Personal Care (PC) staff to determine compliance with SAMM skills and Personal Care evaluation requirements in the calendar year 2023 through the date of the Compliance Review.
• Documentation confirming the completion of SAMM and skills evaluations every six months was missing from three (3) records for the 2024 calendar year reviewed.
• Resident Rights and Disclosures- Resident Disclosures
• EOEA reviewed eight Resident records to confirm compliance with the Disclosure of Rights and Services requirements.
• The required Disclosure forms and notification of the right to bring a Representative prior to the first meeting, were not signed by the Resident, Resident Legal Representative and/or Residence in two (2) records.