Complaint·December 20, 2024

Citations

6 citations recorded^*CCLD

• 1569.312(e)Type B

  1569.312 Basic services requirementsEvery facility required to be licensed under this chapter shall provide at least the following basic services: (e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being. This requirement was not met as evidence by record review of SIR’s, staff schedules and interviews with staff. These disclosed the facility did not have coverage during the NOC shift in 1 of 4 units. This posed a potential health safety and personal rights risk to residents in care.

• 87217(b)Type B

  Facility must safeguard entrusted cash and valuables

  87217 Safeguards for Resident Cash, Personal Property, and Valuables(b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all such articles or cash resources. This requirement was not met as evidence by: Interviews conducted disclosed incontinent supplies are not properly being accounted for and going missing. LPA observation of storage room disclosed residents supplies were missing. This poses a health safety and or personal rights risk to residents in care.

• 87309(a)Type B

  Ensure hazardous items are locked and not unattended

  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 was not met as evidence by: LPA observation during tours completed on 9/10/24 and 9/16/24. Various areas of the facility were observed with items (sharps and chemicals) that pose a danger to residents in care unlocked and accessible.

• 87411(d)Type B

  On-the-job training requirements

  87411 Personnel Requirements - General(d)All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: This requirement was not met as evidence by: review of records. Files review show that staff did not have the required training prior to being placed on the schedule without supervision for the NOC shift. This poses a potential health safety and or personal rights risk to residents in care.

• 87705(c)(4)Type B

  87705 Care of Persons with Dementia(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement was not met as evidence by: review of documentation, tours completed and interviews conducted which all indicate personal care needs (incontinence, grooming, bathing) are not being met. This poses a potential health safety and or personal rights risk to residents in care.

• 87411(a)Type A

  Facility personnel sufficiency and competence

  87411(a) Personnel Requirements – General - Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs… This requirement was not met as evidenced by: Interviews and record review indicated R1 was left in the sun on 7/22/24 for an unknown amount of time resulting in R1 becoming unresponsive and requiring medical attention. This poses an immediate health, safety and or personal rights risk to residents in care. An immediate civil penalty in the amount of $500 was assessed per Title 22.

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