Cardinal Yu-pin Manor

Record findings for communicable tuberculosis conditions

Based on record review, the licensee did not comply with the section cited above in 3 out of 5 resident files reviewed did not contain a TB test( Residents 3,4,5)t which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on interview and record review, the licensee did not comply with the section above in that facility files did not contain documentation of quarterly disaster drills which poses/posed a potential health, safety or personal rights risk to persons in care.

Update reappraisal at required intervals

Based on record review, the licensee did not comply with the section cited above in 2 out of 5 resident files reviewed contained resident reapprasials over a year old ( Residents 3 and 4) which poses/posed a potential health, safety or personal rights risk to persons in care.

Store disinfectants separately from food supplies

Based on observation], the licensee did not comply with the section cited above in LPA observed a can of WD40 on top of fire extinguisher by the front entrance and 2 bottles of cockroach spray in the laundry area which is accessible to residents. which poses an immediate health, safety or personal rights risk to persons in care.

Provide resident hot water for personal care

Based on observation, the licensee did not comply with the section cited above in bathroom in room #29 water temperature tested at 112.2 degrees F. which poses an immediate health, safety or personal rights risk to persons in care.

Include required health screening documents

Based on record review, the licensee did not comply with the section cited above in5 out of 5 staff files did not have a health screening LIC 503 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 training was last provided to staff on 2023 which poses/posed a potential health, safety or personal rights risk to persons in care.

Update reappraisal at required intervals

Based on record review, the licensee did not comply with the section cited above in Resident 2 appraisal was last conducted on 7/5/23 and Resident 3 did not have an appraisal on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Annual routine visit with medical professional

Based on record review, the licensee did not comply with the section cited above in Resident #2 did not have a current medical assessment last conducted on 8/1/23 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 facility does not have a current Emergency Disaster plan LIC610E(03/19) which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, and interview conducted, the administrator did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.

Provide resident hot water for personal care

Based on observation, the licensee did not comply with the section cited above in the hot water temperature was measured at 125 degrees F, which poses an immediate health, safety or personal rights risk to persons in care.

Use slip-resistant surfaces in bathing areas

Based on observation, the licensee did not comply with the section cited above in which resident bathrooms was missing skid matts/strips, which poses/posed a potential health, safety or personal rights risk to persons in care.

Use slip-resistant surfaces in bathing areas

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.

Submit and maintain current mailing address

Based on observation and interview, the licensee did not comply with the section cited above in which S1 is not associated the facility and has work at the facility since 5/13/2020, which poses an immediate health, safety or personal rights risk to persons in care.

Obtain baseline medical assessment before resident admission

Medical AssessmentPrior 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 has not been met as evidenced by:LPAs did not observe current Physician's reports for R5-R19 in the resident files. The some reports were outdated for as many as 12 years. This poses a potential risk to the health and safety of residents in care.

Facility must clear fire safety for bedridden persons

Fire Clearance All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department...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... This evidence has not been met as required by: The facility license was approved to retained 1 bedridden resident and currently LPAs observed there to be 2 bedridden residents(room 15 and room 10) This poses a health and safety risk. **Immediate civil penalty will be assessed**.

Maintain facilities for fire and panic safety

Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.This requirement was not met as evidenced by: LPAs observed a chain and pad lock on the iron exit gate located at the entrance of the facility. This poses a health and safety issue to the residents in care.