Williams-whittle Residential Care Home #3

Maintain facility in clean, safe, sanitary condition

Based on observation, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed the following which require repair or replacement - Blinds on kitchen door are damaged, the wall in bedroom 2 needs repair on previous damage, the back yard fence is leaning and needs stabelization.

Record centrally stored prescriptions and refill data

Based on record review th,e licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care. A record of centrally stored prescription medications for R1 is not maintained for current medications.

Document each PRN medication dose taken

Based on record review, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care. The facility does not maintain a PRN log which contains all elements required in documentation.

Record centrally stored prescriptions and refill data

Based on record review the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care. A current and complete Centrally Stored Medication and Destruction Log is not maintained.

Based on record review, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care. R1's Physician Report dated 5/2023 does not document Diabetes or R1's ability to selfn administer glucose testing with assistance. Additionally, R1 and R2's reports note MCI which required to be updated allually.

Assist residents with self-administered medication

Based on record review, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care. LPA conducted a medication audit. R1's Lorazapam cards for 3pm and 7pm contained additional pills based on the start date as recorded by staff. 3pm - 3 additional, 7pm - 5 additional pills. Additionally, there are multiple blank MAR dates where staff did not initial - unable to confirm if medication was given as ordered.

Ensure hazardous items are locked and not unattended

Based on observation, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care. LPA observed the cleaning/disinfecting supply cabinet in the garage to be unlocked, rubbing alcohol, hydregen peroxide and scissors in an unlocked cabinet in the ofice and cleaning supplies under office sink.

Based on interview, the licensee did not comply with the section cited above in 2 of 2 residents which poses/posed a potential health, safety or personal rights risk to persons in care. Resident P&I logs were not available for review at the facility during the visit.

Maintain facility in clean, safe, sanitary condition

Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPAs observed the refrigerator in the garage needs to be cleaned inside and out, tires in the front yard need to be disposed of and a patio chair needs to be thrown away due to damaged seat.

Ensure hazardous items are locked and not unattended

Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. Cleaning supplies were accessible in the laundry room and closet, scissors were observed in a cup on the kitchen counter.

80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.This requirement was not met as evidenced by: Licensee did not ensure the facility was clean, safe, sanitary and in good repair for the safety and well being of clients, employees and visitors. LPA observed the screen of R1's sliding door is torn and off the track, window screens outside TV room is bent and both kitchen window blinds are in disrepair and dirty.This poses a potential Health, safety or residents rights risk to persons in care.

80070 Client Records (a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.This requirement was not met as evidenced by: Licensee did not ensure that 3/3 resident files were complete and current. LPA observed that R1 and R2 resident files did not contain all required documents. Resident emergency contact information needs to be updated in the event of an emergency for medical personnel.This poses a potential health, safety and resident rights risks to persons in care.