Fremont Hills

Based on observation, the licensee did not comply with the section cited above by having 3 tubs of paint in R1's room, lysol wipes and cleaning spray in R2's room, the tool shed unlocked in the courtyard of the memory care unit, Bissell, Alcohol Antiseptic, staff eyedrop in the backpack, etc. in the memory care unit dining hall which posed an immediate health and safety risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above by not having the current liability insurance on file which poses a potential safety risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in having expired sesame sauce, soy sauce, Hershey chocolate powder, etc. which posed a potential health and safety risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in having R7's toilet, window blinds, and shower soap bar holder in disrepair and R3 and R4's call button that had a paper towel holding the button up which poses a potential safety risk to persons in care.

87468.1(a)(2) Personal Rights of Residents in All Facilities(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This requirement is not met as evidenced: Based on interviews, the licensee did not comply with the section cited above by giving R1 the wrong medication dosage which posed a potential safety risk to person in care.

87309(a) (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances...locked storage and are not left unattended if outside the locked storage.This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by having Fluticasone Propionate Nasal Spray and medication syrup on top of the medication cart unsupervised by staff which poses an immediate health and safety risk to persons in care.

87303(a) Maintenance and Operation(a) The facility shall be clean, safe, sanitary and in good repair at all times...This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above by having the call button system in disrepair which posed a potential safety risk to persons in care.

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) … residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, … and meetings of resident and family groups. This requirement is not met as evidenced by:Resident statement, "They may knock, but then do not wait long enough for me to tell them to come in. It doesn't respect my privacy when they do that."

Based on observation, the licensee did not comply with the section cited above in not having the post of personal rights, nondiscrimination notice, and the right size for the complaint and ombudsman poster which poses a potential health and safety risk to persons in care. Proof of Corrections will be sent to CCLD by POC date.

Based on record review, the licensee did not comply with the section cited above by not having a health screening for S1 and S2 on file. Also, S1, S2, and S5 do not have a TB test on file which poses a potential health and safety risk to persons in care.

87211(a)(1) Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence... This requirement is not met as evidenced by:Based on interview and record review, the administrator did not comply with the section cited above by not reporting an incident to CCL within 7 days of the occurrence which poses a potential health, safety or personal rights risk to persons in care.

87303 Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times... This requirement was not met as evidence by: Based on LPAs interview licensee did not comply with the section above in facility being in good repair, which poses a potential health and safety risk to persons in care.

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on interview and record review the licensee did not comply with the section cited above. Resident R1 left the facility unsupervised which poses a potential risk to health and safety of clients under care.