Follow-up·October 24, 2023

Citations

9 citations recorded^*CCLD

• 87458(a)Type B

  87458 Medical Assessment(a)Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year.-This requiement is not met as evidenced by: -Based on records, the licensee did not comply with the section above for R2's LIC602A signed by PA-C not consistent with MD's assessment. R2 was not followed-up with his MD. These pose potential health, safety, and/or personal rights risks to person in care. This is a re-citation.

• 87203Type A

  87203 Fire SafetyAll facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.-This requirement is not met as evidenced by: -Based on observation and interview, the licensee did not comply with the section above for smoke detectors in R1's room removed which poses immediate safety risk to person in care.Civil penalty is assessed.

• 87303(a)Type B

  87303 Maintenance and Operation87303 Maintenance and Operation(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. -This requirement is not met as evidenced by:-Based on observation, the licensee did not comply with the section above for mouse droppings and protruding drain pipe which pose potential safety risks to persons in care. This is a repeat violation.

• 87309(a)Type A

  87309 Storage Space(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.-This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section above for unlocked storage, shovel in the side yard, weed killer in cabinet without lock in the foyer, wound cleanser in cabinets without lock, and scissors. These pose immediate health and safety risks to persons in care. This is a repeat violation.

• 87458(b)(5)Type B

  87458 Medical Assessment (b) The medical assessment shall include, .. (5) The determination whether the person is ambulatory or nonambulatory ... The assessment shall indicate whether nonambulatory status is based upon the resident’s physical condition, mental condition or both. -Based on record review, the licensee did not comply with the section above for R2's LIC602A indicated bedridden which poses potential safety and/or personal rights risks to persons in care.This is a repeat violation,

• 87465(h)(2)Type A

  87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications..(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. -This requirement is not met as evidenced by:-Based on observation. the licensee did not comply with the section above for medications unlocked in R1's room which poses immediate health and/or personal rights risks to persons in care.This is a repeat violation.

• 87506(a)Type B

  87506 Resident Records(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff-This requirement is not met as evidenced by: -Based on record review, the licensee did not comply with the section above for R2's LIC9172 and Appraisal indicated ambulary, which are not consistent with LIC602A which showed bedridden. These pose potential safety and/or personal rights risks to person in care. This is a repeat violation.

• 87555(b)(24)Type B

  87555 General Food Service Requirements: (b) The following food service requirements shall apply:(24) Pesticides and other toxic substances shall not be stored in food storerooms, kitchen areas, or where kitchen equipment or utensils are stored. -This requirement is not met as evidenced by:-Based on observation, the licensee did not comply with the section above for keeping the weed killer in the cabinet where food supplies are kept which poses potential health and/or personal right rsks to persons in care,

• 87608(a)(3)Type B

  87608 Postural Supports(a) ....Postural supports may be used under the following conditions.(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record.......-This requirememt is not met as evidenced by: -Based on record review, the licensee did not comply with the section above for R2's half bed rails without doctor's order on file which poses potential personal rights risk to person in care.

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