Desired Peace Home Care 2

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: This requirement is not met as evidence by: Based on interviews and record review, licensee did not comply with section cited above by not submitting incident reports and hospice notification to CCLD which poses a potential health and safety risk to the persons in care.

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by having full bed rails for residents who are not on hospice care which poses an immediate health and safety risk to persons in care.

Incidental Medical and Dental Care(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.This requirement was not met as evidenced by: Based on observation and records review licensee failed to maintain medication administration record form for all residents in care which poses/posed a potential health, safety risk to persons in care.

Based on interview , the licensee did not comply with the facility has NOT conducted staff training on infection prevention, symptoms, transmission and PPE use in which poses/posed a potential health, safety risk to persons in care.