Complaint·May 26, 2023

Citations

7 citations recorded^*CCLD

• 87219(f)Type B

  Planned Activities (f) In facilities licensed for 50 persons or more, 1 staff member shall have full-time responsibility to organize, conduct, planned activities... The activities shall be written, planned in advance.. be available to all residents… This requirement is not met as evidenced by. Based on observation & record review Licensee did not provide planned activities as required. This posses potential personal right risk to resident in care.

• 87411(a)Type B

  Facility personnel sufficiency and competence

  87411(a) Personnel Requirements-General. 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, record review Licensee did not insure to have sufficientnumber of compitenat staff. During 8 hours shift staff is only assisting residents requiring extensive care. This possess potential Health & Safety risk to residents in care.

• 87555(b)(6)Type B

  General Food Service Requirements. (b) The following food service requirements shall apply: (6) In facilities for 16 persons or more, menu shall be written at least 1 week in advance & copies of the menu... shall be dated & kept on file... This requirement is not met as evidenced by. LIcensee did not ensure that the facility menu is meeting food services requirement. 5 out of 7 day resident are served the same food for breakfast . This poses a potential personal rights violation to residents in care.

• 87411(d)Type B

  On-the-job training requirements

  87411 Personnel Requirements - General (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance Based on file review, observation, and interviews the licensee failed to provide on the job training to staff. Investigation revealed staff did not receive job specific trainings which poses a potential health andsafety hazard for residents in care.

• 87506(a)Type B

  Maintain separate complete record for each resident

  87506 Resident Record (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. Based on file review, and observation the licensee failed to maintain a complete and current record for residents in care. During record review LPA observed the MAR for 05/20/23 is incomplete. Which poses a potential health and safety hazard for residents in care.

• 87303(a)Type B

  Maintain facility in clean, safe, sanitary condition

  Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair...Maintenance shall include...maintenance services and procedures...of residents, employees and visitors.This requirement was not met at evidenced by: Based on observations and interviews conducted, the licensee failed to ensure that the facility was clean, safe and sanitary on 10/19/2022. LPA observed evidence of rats presence at facility which poses a potential health, safety and personal rights risk to residents in care.

• 87307(d)(2)Type B

  Facility maintenance and healthful environment

  Personal Accommodations and Services. The following space and safety provisions shall apply to all facilities: The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.This requirement was not met as evidenced by: Based on observations and interviews conducted, the licensee failed to provide a safe and healthful environment, on 10/19/2022 LPA and LPM observed evidence of cockroaches in resident bedrooms which poses a potential health, safety and personal rights risk to residents in care.