Follow-up on corrections·June 8, 2023

Citations

4 citations recorded^*CCLD

• 87211(a)(1)Type B

  Report specified resident events within seven days

  87211 Reporting 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 events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement was not met as evidenced by: Facility did not report emergency services responding for R1 which poses a potential health, safety and/or personal rights risk for residents in care.

• 87405(a)(3)Type B

  87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. (3) Ability to maintain or supervise the maintenance of financial and other records. This requirement was not met as evidenced by: Administrator did not provide requested records for the dates of 3/15/23 to 03/31/23 for the signal system at the facilty which poses a potential health, safety and/or personal rights risk to residents in care.

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• 87411(a)Type B

  Facility personnel sufficiency and competence

  (a) 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 me evident by: Based on LPA's interviews and record reviews, on 3/29/2023, the Licensee did not ensure staff were present, for approximately 30 minutes, to respond to the facilities signall system, which poses a potential health and safety risk to persons in care.

• 1569.49(c)(3)Type A

  1569.49 Civil penalties; regulations setting forth appeal procedures for deficiencies (c) The department shall assess an immediate civil penalty of five hundred dollars ($500) per violation and one hundred dollars ($100) for each day the violation continues after citation for any of the following serious violations:(3) Absence of supervision as required by statute or regulation. This regulation was not met as evidenced by: On 03/29/23 Facility did not have staff present in the faciltiy and did not provide care to R1 for at least 30 minutes which poses an immediate health, safety, and/or personnnel rights risks to residents in care.