St. Catherine's Home Care, Inc.

Record dose details and resident medication response

Based on interview conducted, observations, and records reviewed, R2’s medication Nitrofurantoin Mono-MCR observed with 7 capsules left in bubble pack not recorded in the resident’s MAR, which poses an immediate health and safety risk for the person in care.

Store centrally held medications in locked secure place

Based on observation, R1, R2, and R3’s PRN medications were observed stored in the refrigerator bottom drawer unlock accessible to the residents which poses an immediate health, safety or personal rights risk to persons in care.

Safe, healthful, comfortable accommodations

Based on observation and interview conducted with Licensee, the licensee did not comply with the section cited above when video cameras with audio was observed installed in the kitchen and front livingroom which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review and interview, residents’ files were reviewed and observed R1 do not have an appraisal (Lic 603), Needs and services plan (Lic 625), ID and Emergency Information (Lic 601), and Medical Consent form (Lic 627C) on file, which poses/posed a potential health, safety or personal rights risk to persons in care.

Facility must keep complete hospice care plan on file

Based on record review, the licensee did not comply with the section cited above when LPA reviewed R2 and R3who are currently receiving hospice care with no current hospice care plan on file, which poses a potential health or personalrights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above when LPA reviewed R1, R2 and R3who are currently receiving hospice care with no current hospice care plan on file, which poses a potential health or personalrights risk to persons in care

Facility has overdue Annuals and Late Fees.

First aid training requirements

Based on interview conducted and records reviewed, S1’s files was reviewed and did not have current First Aid training on file, this poses an immediate health and safety risk for the residents in care.

Maintain required personnel records for staff

Based on records review, Licensee/ Administrator and S2 do not have all the required personnel records maintained on file, which poses a potential health or personal rights risk to persons in care.

Based on records review and interview conducted, S2 completed TB testing on 08/02/2019, which poses a potential risk to the health and safety of the residents.

Ensure hazardous items are locked and not unattended

Based on observation, the Licensee did not comply with the section cited above when LPA arrived and observed alcohol spray bottle on kitchen counter unlock accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.

Dispose of unused medications with required witness

Based on interview conducted and observation, LPA and Licensee observed S1 taking R1’s refusal medications tablet and placing it in S1’s pocket, poses/posed a potential health and safety and personal rights risk to the resident in care.

Maintain physician order documentation in resident record

Based on interview conducted, observation, and records reviewed, R1, R2, and R3 uses half bed rail on hospital bed with no doctor’s order, which poses/posed a potential health and safety and personal rights risk to the resident in care.

Give PRN medication by physician order

Based on observation, records reviewed, and interview conducted, R1’s medication Quetiapine 25mg was administered daily. Medication was checked LPA and Licensee and observed not administered as directed by physician, which poses/posed an immediate health and safety risk for the person in care.

Food quality controls and rejected damaged goods

Based on observation, expired perishable and expired canned foods were observed, poses/posed an immediate health, safety or personal rights risk to persons in care.

Based on interviews and observation, facility does not have a carbon monoxide detector which poses a potential health and safety risks to persons in care.

Limit staff assistance with self-administered drugs

Based on interviews and records review, the licensee did not ensure staff administer medication to resident as prescribed by physicians, which poses an immediate health and safety risks to persons in care.

Fire approval and staff access to unlock systems

Based on observation, the licensee did not comply with the section cited above when medications were observed stored on kitchen counter and in resident’s dresser unlock accessible to residents. Cleaning chemicals were observed stored under kitchen sink unlock accessible to residents this poses an immediately health, safety or personal rights risk to persons in care.

Maintain required personnel records for staff

87412 Personnel Records (a)The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee.This requirement was not met as evidenced by: Based on observation, Administrator was able to provide for review the staff First Aid/CPR certification for two staff out of the four staff. Administrator did not have additional personnel records for the facility staff. This poses a potential health, safety or personal rights risk to persons in care.

Licensee did not ensure all medications were centrally stored and locked when LPA arrived for inspection and observed R1’s medications in a medication cup on kitchen counter. At approximately 11:08 AM, LPA and caregiver observed two Vitamin bottles and PRN medication Nystatin Topical Powder on R2's personal table in front of the resident in the resident bedroom. This poses an immediate health, safety or personal rights risk to persons in care.

Conformance with applicable laws and regulations

Based on observation, Fire Extinguisher has a service date of 07/16/2019, which poses an immediate health and safety risk to the residents.

Give PRN medication by physician order

Based on observation, LPA reviewed all residents’ MARS and observed that they have not been updated since 05/10/23.

Based on observation and record review, the licensee did not comply with the section cited above. Administrator certification for S1 expired on 10/28/2020. Licensee admitted she has not had time to complete the required training for recertification and has not submitted an application for renewal of the Administrator certificate, which poses an immediate health, safety or personal rights risk to persons in care.

Health screening and fitness requirements

Based on record review, the licensee did not comply with the section cited above. Licensee could not produce health screenings for S1 and S2, which poses/posed a potential health, safety or personal rights risk to persons in care.

Maintain facility in clean, safe, sanitary condition

Based on observation and interview, LPA found a shovel, a pair of shears, and four unused metal wire tomato cages in backyard. LPA observed multiple areas of tiled back patio with cracked tiles that had loose shards of broken tile. LPA observed outside fire exit fence gate was stuck, and difficult to unlatch and push open, all of which poses/posed a potential health, safety or personal rights risk to persons in care.