Bluemeadow Care

(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:This requriment was not met as evidence by: Based on observation, the licensee did not comply with the section cited above in having staff sleeping in the garage which poses a potential personal rights risk to persons in care.

(h) The following requirements shall apply to medications which are centrally stored:(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 was not met as evidence by: Based on LPA's observation the licensee did not coply with the section cited above by med closet and kitchen drawer containing centerally stored medication unlocked which posed an immediate safety risk to residents in care.

(h) The following requirements shall apply to medications which are centrally stored(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.:This requirment was not met evidence by: Based on LPA's observation and interview the licensee did not coply with the section cited above by having perscription medication transferred into a container which posed a potential safety and personnel rights risk to residents in care.

Based on record review, the licensee did not comply with the section cited above in 4 out of 5resident records review not having an up to date appraisal of needs and services which poses a potential personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in not having done any quaterly drills in 2025 which poses a potential safety risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in hot water temprature not measuring in range which poses a potential health and, personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in having S2 sleep in the living room at night which poses a potential personal rights risk to persons in care.

Based on observation, interview, and record review, the licensee did not comply with the section cited above in having an unidentified uncleared individual working which poses an immediate health, safety and personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in not having enough food available which poses a potential personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in not having complete staff files which poses a potential personal rights risk to persons in care.

Based on observation], the licensee did not comply with the section cited above in not having the required information posted which poses a potential personal rights risk to persons in care.

Based on observation the licensee did not comply with the section cited above in not having the required sign posted which poses a potential personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in residents records being incomplete which poses a potential personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above inhaving a knife accesable to residents which poses an immediate safety risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in clients not having an up to date medical which poses a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in not having all required staff first aid trained which poses a potential health, and safety risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in not having staff up to date on trainings which poses a potential health, safety and personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in not having record of disaster drills which poses a potential safety risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in not having scheduled activities which poses a potential personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in having screens ripped which poses a potential personal rights risk to persons in care.

(h) The following requirements shall apply to medications which are centrally stored:(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.This requirement was not met as evidence by: Based on LPA's observation licensee did not coply with the section cited above by having medication transferred into a weekly pill organizer which poses a potential health and safety risk to residents in care.

Based on interview and record review, the licensee did not comply with the section cited above by not first aid and amergency procedure training with night shfit staff which poses a potential health and safety risk to persons in care.

Based on record review, Licensee did not comply with the section cited above by not obtaining the training for S2 which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above by not completing training requirements for S2 which poses a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above by not having a record of emergency drill which poses a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above by not having required training for S2 once employed which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation and interview, the licensee did not comply with the section cited above. LPA observed garage is being utilized as a sleeping area for staff overnight which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above by maintaing hot water in shared resident's bathroom at 141 degrees F which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above by. Based observation, hot water is maintained at 141 degrees F and no warning sign was posted which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above by not having the required training for S2 which pose a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above by not obtaining a health screening and TB test for S1 and S2 which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above by not having complete records S1 and S2 which poses a potential health, safety or personal rights risk to persons in care.

Based on record review,, the licensee did not comply with the section cited above by not obtaining training required for S2 which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above by not posting personal rights and nondiscrimination notice which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above by not maintaing R5's record at facility which poses a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above by not completing the required training for S3 which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above by not having a staff for each shift with CPR training which poses a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above by not having the required training for S2 prior to employment which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above by not having an Emergency Disaster Plan on file which poses a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above by not having current first aid training for S1, S2 and S3 which poses a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above by not maintaing records for S1 and S2 which poses a potential health, safety or personal rights risk to persons in care.

87466 OBSERVATION OF THE RESIDENTThe licensee shall ensure that residents are regularly observed for changes in physical......changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: Based on the Department’s interviews and record review, Licensee did not comply with the regulation cited above. Facility staff were instructed by Home Health nurse to supervise R1 at all times. On 5/28/2020, R1 fell off the wheelchair which resulted to R1 sustaining a cut on the chin. On 6/9/2020, staff informed Home Health nurse that R1’s eyes have been bleeding for two days. R1’s primary doctor was not notified.

87411(a)(1)(D) REPORT 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 of any of the…(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any residents. This requirement is not met as evidenced by: Based on record review, Licensee did not comply with the regulation cited above. Facility did not submit incident reports for when R1 fell off the wheelchair and sustained a cut on the chin in April 2020. In addition on May 28, 2020 where R1 was observed with bleeding eyes which poses a potential health and safety risk to persons in care.

87705(c)(5) CARE OF PERSONS WITH DEMENTIA(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(5) Each resident with dementia shall have an .... and a reappraisal done at least annually... This requirement is not met as evidenced by: Based on record review, Licensee did not comply with the regulation cited above. LPAs observed R4 does not have an updated appraisal on file which poses a potential health and safety risk to persons in care.

87705(f)(2) CARE OF PERSONS WITH DEMENTIA(f)The following shall be stored inaccessible to residents with dementia:(2)...and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Based on observation, Licensee did not comply with regulation cited above. LPAs observed unlocked cleaning supplies in unlocked laundry room which poses an immediate health and safety risk to persons in care.

1569.269(a)(10) ENUMERATED RIGHTS; SEVERABILITY(a) Residents of residential care facilities for the elderly shall have all of the following rights: (10)To be free from neglect...This requirement is not met as evidenced by: Based on the Department’s interviews and record review, Licensee did not comply with the regulation cited above. In April 2020, Home Health nurse instructed staff to off-load pressure to R1’s right heel at all times and to reposition every 2 hours. Nurse observed R1’s wound pressed against the bed twice. On 6/9/2020, R1 was admitted to hospital and pressure injury was diagnosed at Stage 4. Bone was exposed and test results revealed R1 had Osteomyelitis due to bacterial infection which infected R1’s bloodstream.

87568.1 Personal Rights of Residents in All Facilities (a) Residents...shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. Thiis requirment was not met as evidence by: Based on observation, Licensee did not comply with the regulation cited above. LPA observed a latch installed in the front main entrance door and R1's exit door which poses an immediate health and safety risk to residents in care.

Based on record review, licensee did not comply with the section cited above. LPAs observed no Emergency Disaster Plan is maintained at facility which poses a potential health and safety risk to persons in care.