Notre Dame du Lac

• Service and Service Coordination Requirements-Emergency Response
• EOEA reviewed the Personalized Emergency Response procedures developed to provide timely assistance to a Resident in the event of an emergency needs situation.
• During the first ten days of the months of December 2022, April 2023 and June 2024 there were 43 e-call response times over the fifteen (15) minutes required by Residence policy.

Dietary Reviews

• EOEA reviewed the Residence's dietary plan reviews from 2022 through the date of the Compliance Review to confirm consistency with the most recent edition of the Dietary Guidelines.
• Menus lacked the inclusion of the required language designating that the meal selections meet the minimum dietary standards of the daily recommended allowances of sodium, sugar and fat content as established by the Food and Nutrition Board of the National Research Council of the National Academy of Sciences.
• Service and Service Coordination- Special Care
• EOEA reviewed the Special Care Residence (SCR) operations review from calendar year 2022 through the date of the Compliance Review to verify that the SCR is being administered with all the required safeguards.
• Documentation to support that the Residence conducted an SCR operations review was missing for the second half of 2023 and the first half of the 2024 calendar years reviewed.
• On the day of the Compliance Review, EOEA identified an environmental hazard of all windows on the second floor SCR are able to be completely opened; potentially allowing exit seeking, memory care Residents to pass through the windows and fall to the ground one story below.
• General Requirements for an Assisted Living Residence (ALR)-
• EOEA reviewed eleven (11) Resident Records reviewing documentation from September 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

• Three (3) records were missing documentation of a reassessment review being completed every six months.

Service Plan Development and Requirements

• Five (5) records were missing documentation of a service plan review being completed every six months.

Bed Rail Assessments

• EOEA reviewed the Residence records of 20 Residents utilizing bed rails / U-bars or similar devices for the period of 2022 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 eleven (11) Residents noting that the Resident can independently navigate around a bed rail/ U-bar for the calendar years reviewed was missing.
• Quality Assurance and Performance Improvement
• EOEA 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 September 13, 2022, through the date of the Compliance Review.

Service Planning

• Documentation of the date the audit was conducted was missing for the 2022 and 2023 calendar years reviewed.

Resident Safety Assurances

• Documentation of the target date and the staff person responsible for follow-up action and clear outcomes was missing for the 2022 and 2023 calendar years reviewed.

Medication Quality Plan

• EOEA reviewed the Residence's quarterly medication documentation audits from September 13, 2022 through the date of the Compliance Review to ensure compliance with SAMM and Residence policies.
• Documentation of a target date for follow-up and the staff person responsible was missing in the first quarter of 2023.
• Documentation of Quarterly Medication Reviews being completed for the last three quarters of 2023 and the first two quarters of 2024 was missing.

Medication administration observation

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

SAMM

• EOEA observed two (2) Resident's family filled medication containers missing labels of the Resident's name and apartment number as per policy.
• EOEA observed one (1) Resident's medication storage unit containing expired medications.
• EOEA observed one (1) Resident's medication storage unit containing a loose unidentified pill.
• Exemption CExemption CEOEA observed one (1) PC staff forget to prompt the Resident for assistance with a scheduled .
• EOEA observed three (3) PC staff not perform hand hygiene prior to medication assistance.
• Reporting Resident-specific Emergencies-Evacuation Drills and Rehearsals
• EOEA reviewed the Residence's Emergency Plan to ensure compliance that the Residence can address potential disasters and emergencies.
• Documentation of fire drills was missing for the second and third shifts for the 2022 calendar year reviewed.
• Documentation of an elopement drill was missing for the first and third shifts for the 2022 calendar year reviewed.
• Documentation of an elopement drill was missing for all three shifts for the 2023 calendar year reviewed.

Incident Reports

• EOEA reviewed the Residence records and incident reports from September 2022 through the date of the Compliance Review to determine whether the Residence complied with the requirement to qualifying incidents to EOEA within 24 hours after the occurrence of the incident or accident.
• The Residence filed 31 incident reports greater than 24 hours after the occurrence of the incident or accident.
• Record Requirements-

Resident Record

• EOEA reviewed eleven (11) Resident records to determine compliance with record requirements.
• A Disclosure of Rights and Services was missing in two (2) Resident records.

Correspondence Log

• EOEA reviewed the documentation maintained in two 90-day correspondence logs to communicate information necessary to maintain the continuity of care for Residents.
• The Special Care Residence log did not consistently document for each 24-hour period in the Correspondence Log.
• Staffing Requirements- Staffing Levels
• EOEA reviewed the Residence records to determine compliance with Staffing Level requirements.
• Documentation to confirm the Residence conducted quarterly staffing level assessments was missing for the last quarter of 2022, all four quarters of 2023 and the first two quarters of 2024.
• Training Requirements-

Training Needs Assessment

• EOEA reviewed the Residence records to determine compliance with annual training needs assessment requirements.
• Documentation of annual training needs assessments was missing for the 2022 and 2023 calendar years reviewed.

Introductory Visit and Review

• EOEA reviewed the records of eleven (11) Residents to determine compliance with the requirements that a nurse review 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:
• Eleven (11) 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

• EOEA reviewed the records of six (6) Personal Care (PC) staff to determine compliance with Personal Care evaluation requirements in the calendar year 2022 through the date of the Compliance Review.
• Documentation confirming the completion of Personal Care (PC) skills and SAMM evaluations every six months was missing from five (5) records.
• Certification – Renewal Certification Procedures
• The application for renewal of Certification must be filed and date-stamped at EOEA at least 30 days before the stated expiration date of the Certification.
• As of the date of the compliance review, the Residence has not submitted an application for renewal which was due to EOEA on July 17, 2024.