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Inspection visit

Routine inspection

TAR SPRINGS HOME CARELicense 15720919610 citations on this visit
10 citations recorded

Inspector’s narrative

What the inspector wrote

Licensing Program Analysts (LPAs) Shawna Doucette and Brianna Miranda arrived at the facility unannounced to conduct the Required Annual Inspection. LPA disclosed the purpose of the visit and was granted entry into the facility by Staff Beatriz Ancheta. Administrator Socorro Telmo responded to assist with the visit. When LPAs arrived staff struggled with unlocking and opening the door. When LPAs entered the facility a separate lock was observed on the front door. LPA asked Administrator why there was a separate lock. Administrator stated they had a resident that wandered and it was to keep the resident in. When LPAs entered the facility there was a smell of urine. Facility had delay egress turned off for the front and garage door. The back door did not have a delay egress. LPA took photos. A tour of the facility was conducted with Staff. LPA Doucette observed 6 bedrooms in the facility. While touring the facility, Hot water temperature was measured 106.9 F. Facility is at 76 F. Kitchen toured, supply of food observed and food stored properly for perishable and nonperishable. Medications were stored in a locked cabinet in kitchen. Cleaning supplies were in a locked cabinet under the kitchen and in locked cabinet in garage. Smoke detectors were checked and operating. Carbon monoxide was not working. Facility has a pull station fire alarm. Fire extinguisher has a service date of 1/11/24. Resident, medication, and staff records were reviewed. R1's centrally stored log was reviewed and errors were observed. Amlodipine and Esomepradole were not logged on the centrally stored log. Morphine prescription showed quantity of 30 however it was crossed out and handwritten in quantity 52. PRN log shows 34 were given out of the 30 or 52 with 23 left. Morphine start date shows 03/4/24. LPA took photos. Staff did not have hospice training for residents on hospice. Hospice care plans did not meet regulation requirements. Deficiencies were observed and will be cited under Title 22, Division 6. See LIC 809D. Civil Penalty was issued. An exit interview was conducted with the Administrator. A copy of this report, plan of correction and appeal rights were discussed and left with the Administrator, Socorro Telmo, whose signature on this form confirms receipt of these documents.

Citations

10 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 1569.311Type A

    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.

  • 87405(a)Type A

    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.

  • 87465(a)(4)Type A

    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.

  • 87465(a)(6)Type B

    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.

  • 87465(h)(4)Type A

    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.

  • 87606(f)(1)(A)Type B

    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.

  • 87625(b)(3)Type B

    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.

  • 87633(a)Type B

    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.

  • 87705(j)Type A

    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.

  • 87705(l)(3)Type A

    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.

FAQ · About this visit

Common questions about this visit

What happened during the May 23, 2024 inspection of TAR SPRINGS HOME CARE?

This was an inspection of TAR SPRINGS HOME CARE on May 23, 2024. 10 citations were issued: 6 Type A (serious) and 4 Type B.

Were any citations issued to TAR SPRINGS HOME CARE on May 23, 2024?

Yes, 10 citations were issued (6 Type A, 4 Type B). The first citation was for: "Based on observation, the licensee did not comply with the section cited above in Licensee not having a working carbon m..."

What type of inspection was this?

This was an inspection. Inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.