Tar Springs Home Care

Record findings for communicable tuberculosis conditions

Based on records reviewed, R1 and R2 do not have TB result on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Maintain physician order documentation in resident record

Based on interview conducted, observation, and records reviewed, R1 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.

Store centrally held medications in locked secure place

Based on observation and interviews conducted, the licensee did not comply with the section cited above when LPA and L1 observed R2’s medication Multivitamin stored unlock on television stand in resident’s room and R4 medication Milk of Magnesia stored unlock on dresser in the resident’s room which poses an immediate health, safety or personal rights risk to person in care.

Record dose details and resident medication response

Based on observations, records reviewed, and interviews conducted, S1 administered R1 medication Levothyroxine 75mcg and Donepezil Hcl 5mg in the morning ON 04/29/25 at 08:00am, and did not record in the resident’s MARs, which poses/ posed a potential health and safety risk for the person in care.

Label and preserve medicine compliance standards

Based on record review, the licensee did not comply with the section cited above in R1's quantity of 30 label was crossed out and 52 was handwritten in, which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in Licensee did not include an evacuation plan of bedridden residents in disaster plan, which poses/posed a potential health, safety or personal rights risk to persons in care.

Maintain cleanliness and prevent incontinence odors

Based on observation and interview, the licensee did not comply with the section cited above in Licensee did not ensure residents incontinence was changed every 2 hours which caused an odor of urine, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in Licensee does not have a care plan that meets the requirements and does not have staff training regarding hospice care for R1, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation and interview, the licensee did not comply with the section cited above in Licensee did not have the front door and the garage door delay egrees turned on and the back door to the backyard did not have a delay egrees, which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation interview, the licensee did not comply with the section cited above in Licensee had an extra lock on the front door to prevent residents from exiting the facility, which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in Licensee not having a working carbon monoxide detector, which poses an immediate health, safety or personal rights risk to persons in care. Civil Penalty issued.

Certified administrator requirements and substitute coverage

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Administrator receiving multiple citations and is non compliant in Health and Safety and Title 22 in various areas, which poses an immediate health, safety or personal rights risk to persons in care.

Assist residents with self-administered medication

Based on record review, the licensee did not comply with the section cited above in Licensee had two different start dates for R1's medication and R1 missed a medication, which poses an immediate health, safety or personal rights risk to persons in care.

Maintain records of centrally stored medication dosages

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Licensee did not log 2 of R1's medications on the centrally stored log, which poses/posed a potential health, safety or personal rights risk to persons in care.

Each terminal resident needs a written hospice care plan

87633 Hospice Care of Terminally Ill Residents (a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician...who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility when all of the following conditions are met: (4) A written hospice care plan which specifies the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the facility is developed for each terminally ill resident or prospective resident by that resident’s hospice agency and agreed to by the licensee and the resident, or prospective resident, or the resident’s or prospective resident’s Health Care Surrogate Decision Maker, if any, prior to the initiation of hospice services in the facility for that resident, and all hospice care plans are fully implemented by the licensee and by the hospice(s). This requirement was not met as evidenced by LPAs records review and interview with Administrator. There are no hospice care plans in resident files. If not corrected, this poses an immediate Health and Safety risk to residents in care.

87608 Postural Supports(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself Postural supports may be used under the following conditions.(5) Under no circumstances shall postural supports include ...(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 was not as evidenced by LPAs observation of records. There is no order in Resident R1's file for full bed rails. If not corrected, this poses an immediate Health and Safety risk to residents in care.

Maintain fire clearance before retaining specified persons

87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. This requirement was not met as evidenced by: Licensee has 2 out of 5 residents bedridden and is only fire cleared for one resident in room 5. R1 is in room 1 and R2 is in room 2 which are not fire cleared rooms which poses and immediate health safety and or personal rights risk to residents in care.

Assist residents with self-administered medication

Based on observation, interview, and record review, the licensee did not comply with the section cited above in R1 showing a start date of a medication on 2/8/23 and a pill bottle count of 30 which is prescribed to be administered daily and shows not given for March, April and May of 2023 which poses an immediate health, safety or personal rights risk to persons in care.

Maintain records of centrally stored medication dosages

Based on observation, interview and record review, the licensee did not comply with the section cited above in not logging a medication for R1 since 2/8/23 which only shows a pill count of 30 and should be administered daily which poses/posed a potential health, safety or personal rights risk to persons in care.