Prospect Manor

Based on observation, the licensee did not comply with the section cited above. Facility has one shelf broken in the supply room. One sliding door is broken in room 108 which poses 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. LPA tested the water temperature between 105.4 - 121.5 degrees F which is not within the required range of 105.0 -120 degrees F. which poses/posed a potential health, safety or personal rights risk to persons in care.

87211 Reporting Requirements(a) Each licensee shall furnish to the ...g: (2) Occurrences, ...outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents...This requirement is not met as evidence by: Based on interviews and record review administrator failed to inform responsible party of incidents which poses a potential threat to the health, safety, or personal rights of the persons in care.

87411 Personnel Requirements - General (a) 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 met as evidenced by: Based on interviews and record review, R1 who cannot leave the facility unassisted, eloped from the facility which posed an immediate health and safety risk to residents in care.

Based on observation, the licensee did not comply with the section cited above in 2 out of 6 rooms observed, room #216 and 224 did not have skid mat/strip 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 2 out of 6 bathrooms were water temperature was observed and read as follow in room #110 temperature was measured at 122.0 degrees F., and in room #224 water temperature was testd at 126.8 which poses an immediate health, safety or personal rights risk to persons in care.

Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, ... such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.This requirement is not met as evidence by: Based on documents review and interviews conducted licensee did not ensure R1 was properly assess or reasses based on changes in condition which poses an immediate health, safety, or personal right to the persons in care.

87458 Medical Assessment (a)(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by: R1 LIC602 when admitted was not in resident's file and the LIC602A dated on 11/22/2022 was signed by medical doctor who stated he did not have R1 as patient.

False Claims: No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.This deficiency was evidenced by the following: During the course of a complaint investigation, Facility provided hand written documentation indicating that S2 had provided wound care to R1 on several occasions. Both S1 and S2 told the department that wound care was not provided.

87211(a)(1) 87211 Reporting Requirements: (a) Each licensee shall furnish..: (1)A written report shall be submitted to the licensing agency... within seven days of the occurrence...(D)Any incident which threatens the welfare, safety or health of any resident.This requirement is not met as evidence by: Facility did not report incidents when resident refused wound care during the months of July, August, and September, 2023

Additional Personal Rights of Residents in Privately Operated Facilities (a)...: To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.This requirement is not met as evidence by: Based on department interviews conducted and documents reviewed licensee failed to ensure R1 did not develop a wound and neglected wound care by retaining R1 with stage 4 wound which poses an immediate risk to the health, safety, or personal rights to the persons in care. *Immediate Civil Penalty for $500 is being issue*

Based on observation, the licensee did not comply with the section cited above in kitchen wall by stove was observed caved into the kitchen leaving a gap between the floor and the wall of about 3 in x 4 ft in, shower faucet in room 207 was cracked and half way gone 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 water temperature tested in room #122 tested at 122.0 degrees F., room #118 tested at 130.6 degrees F., room #223 tested at 138.3 degrees F., which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, interview, and record review, the licensee did not comply with the section cited above in R2's medication filled on 1/25/24 was out and LVN stated to have provided R2 additional pills to the dosage prescribed by the physician which poses an immediate health, safety or personal rights risk to persons in care.

Personnel Requirements - General(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs..... Based on interviews, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. A staff was caught sleeping on the job.

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).This requirement is not met as evidenced by: Based on observation, resident room #108 water temperature read at 99.8 degrees F, resident room #201 water temperature read at 96.8 degrees F, resident room #209 water temperature read at 95.4 degrees F, resident room #220 water temperature read at 99.1 degrees F, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.This requirement is not met as evidenced by: Based on observation, water temperature in kitchen was measured at 184.1 degrees F, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.

Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.This standard was not met as evidenced by: S1 admitted to hugging and kissing R1 on R1’s lips on several occasions. S1 admitted being caught in R1’s closet by S2 and stated he/she hid in the closet because S1 knew the situation “looked bad”.

87465 Incidental Medical and Dental Record: (e) For every prescription and nonprescription... there shall be a signed, ..., and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.This requirement is not met as evidence by: Based on observation licensee did not ensure medication for R2 had the proper pharmacy label which poses a potential risk to the health, personal rights, or safety of the residents in care.

87465 Incidental Medical and Dental Care: (a) A plan... shall be developed by each facility... (6) ... a record of dosages of medications which are centrally stored shall be maintained by the facility.This requirement is not met as evidence by: Based on observation licensee did not ensure Med techs are recording medication dosages provide to the residents at each dose for R1,R2,R3,R4,R5,R6 review which poses a potential risk to the health, personal rights, or safety of the residents in care.

87303 Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.This requirement is not met as evidence by: Based on interviews and documents reviewed licensee did not ensure elevator was in working conditions at all times wich poses a potential health, safety, or personal rights risk for residents in care.

87618 Oxygen Administration-Gas and Liquid:(b)... the licensee shall be responsible for the following: (3) Ensuring that the use of oxygen equipment meets the following requirements: (C)Smoking shall be prohibited where oxygen is in use.This requirement is not met as evidency by: Based on observation and interviews conducted residents in room 210, and 222 were observed smoking in rooms/balcony which poses an immediate health, safety, or personal rights risk to persons in care.

87303 Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.This requirement is not met as evidence by: Based on observation facility did not ensure facility is in good repair as room #210 has a balcony screen door off rails, #105 ceiling is peeling in three areas, 1 middle window in 2nd floor hallway crack and 1 window screen ripped and leak in dinning room which poses a potential health, safety, or personal risk to persons in care.

87303 Maintenance and Operation: (e)Water supplies and plumbing fixtures shall be maintained as follows: (2).... Hot water temperature controls shall be maintained to automatically regulate.. temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidence by: Based on observation facility failed to maintain water temperature within the required 105-120 temperature as read in rooms #105 at 77.6 degrees F, #107 at 99.4 degrees F and, #210 at 96.1 degrees F which poses a potential health, safety, or personal rights risk to person in care.

87555 General Food Service Requeriments: (a) The following food service requirements shall apply: (21) Freezers... shall be maintained at a temperature of 0 degrees F ..., and refrigerators... shall maintain a maximum temperature of 40 degrees F ....This requirement is not met as evidence by: Based on LPA observation, administrator did not ensure refrigerator and freezer temperature were under the require temperature as observed freezer at 20 degrees, and refrigerator at 45.2 degrees which poses an immediate health, safety, or personal rights risk to persons in care.

87618 Oxygen Administration: (b) In addition to Section 87611(b), the licensee shall be responsible for the following: (3) Ensuring that the use of oxygen equipment meets the following requirements: (I) Equipment shall be removed from the facility when no longer in use by the resident.This requirement is not met as evidence by: Based on observation during facility's tour LPA(s) observed two oxygen tanks in room #229 kept as storage above room#121 were a smoldering fire occured on 6/4/21 which poses an immediate health, safety, or personal rights risk to the persons in care.

Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (5) The licensee shall assist residents with self-administered medications as needed. This deficiency was evidenced by the following: Interviews conducted with staff and residents confirmed medication were not being given as prescribed. The resident’s MAR was also not being completed properly.

General Food Service Requirements(b) The following food service requirements shall apply:(18) Sufficient food service personnel shall be employed, trained and their working hours scheduled to meet the needs of residents. This deficiency was evidenced by the following: Interviews conducted with staff and residents confirmed the facility food was not of good quality when TM1 was operating and many times food was brought in from outside because there was no cook.

Personal Accommodations and Services (a) The following provisions shall apply:(3) The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of:(F) Basic laundry service (washing, drying, and ironing of personal clothing). This deficiency was evidenced by the following: 1 resident stated there was insufficient staff to do laundry when TM1 was operating the facility. Staff reported residents complained about laundry not being done and also that there was no on assigned to do laundry when TM1 was there.

Resident Records(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff This deficiency was evidenced by the following: Staff confirmed records were disorganized when TM1 was operating the facility. Also the MARs reviewed confirmed the records were not being completed as required.

Managed Incontinence(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This deficiency was evidenced by the following: TM2 reported that incontinent residents were assessed and many had redness consistent with not being changed often. Other staff indicated that when TM1 was operating the facility there was insufficient staff to change residents and staff would find residents wet.

87461(a)(1) Mental Condition: 87461(a)(1): The facility shall determine the amount of supervision necessary by assessing the mental status of the prospective resident to determine if the individual:(1) tends to wander. This requirement was not met as evidenced by: Based on interviews and records reviews, the licensee did not ensure that R1 was supervised and accompanied when leaving the facility on two occasions on 12/26/20 and 12/29/20. This poses an immediate safety risk to persons in care.

87468.1(a)(15) Personal Rights of Residents in all facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (15) To send and receive unopened correspondence in a prompt manner. This requirement was not met as evidenced by: Based on interviews, the licensee did not ensure that residents received their mail in a prompt manner daily. This poses a potential risk to personal rights of persons in care.