Brethren Hillcrest Homes

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 is not being met as evidenced by: Staff interviews disclosed six (6) out of ten (10) staff felt there was an insufficient number of staff during the night shift. Four (4) of six (6) residents interviewed confirmed concerns with staffing: one disclosed there is one staff on shift at night and when the resident called for help it took forty-five minutes for staff to respond, one stated there was a staffing problem, one stated staff are not capable of meeting residents needs and one stated staff are overworked which poses a potential risk to resident in care.

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 is not being met as evidenced by: Overnight staff has had to seek the assistance of the security guard to assist residents due to lack of qualified staff.

87466 Observation of the ResidentThe licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance ...........and the resident's responsible person, if any. The requirement was not met as evidenced by LPA's interview and recorded reviewIt was repored that R1 was complaint of pain and staff did not report or notify any family or upper management about R1’s fall which posed a potenital risk for residents in care

87465 Incidental Medical and Dental Care (j)In all facilities licensed for sixteen (16) persons or more, one or more employees shall be designated as having primary responsibility for assuring that each resident receives needed first aid and needed emergency medical services and for assisting residents as needed with self-administration of medications. The names of the staff employees so responsible and the designated procedures shall be documented and made known to all residents and staff. The requirement is not met as evidenced by LPA's observation and record review, R1's medication Quetiapine 25mg was not taken from June 5th to 11th, 2022 and the staff was not able to explain to LPA why R1 was not taking which is potential risk to residents in care

Based on observation and record review, the licensee did not comply with the section cited above in 3 residents medication 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 by not having an operable smoke alarm in the birch court side of the building which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in 5 bathrooms which poses an immediate health, safety or personal rights risk to persons in care.