Treasure Heritage

Facility personnel sufficiency and competence

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 evidence by: Based on interviews, record review and observations, S2's CPR is expired, training documentation could not be provided and LPA observed S2 to have left all (3) residents alone which poses an immediate health, safety or personal rights risk to persons in care.

Grounds for eviction listed for residents

87224 Eviction Procedures (a) Thelicensee may evict a resident for one or more of the reasons listed...Thirty (30) days written notice to the resident is required...This requirement is not met by: Based on interviews, the Licensee/administrator failed to ensure Resident 1 (R1) was given the proper 30 (thirty) day notice for eviction. R1 was not allowed back to the facility after hospitalization discharge. This posed an immediate health and safety risk to residents in care.

Record findings for communicable tuberculosis conditions

Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 5 resident (R3) did not have TB exam results on file which poses a potential health, safety or personal rights risk to persons in care.

Report specified resident events within seven days

Based on record review and LPA's interview with the administrator, the licensee did not comply with the section cited above in not reporting within seven days of the occurrence unusual incident/injury regarding R2 to CCL which 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 one (1) out of three (3) residents in care by not having results of a communicable tuberculosis exam on file for resident #2 (R2) which poses a potential health, safety or personal rights risk to persons in care.

87470(c) Infection Control Requirements shall be developed by the licensee... (1) The Infection Control Plan shall include: (F) Staff shall demonstrate knowledge... appropriate to the job assigned and.. This requirement is not met as evidenced by:Based on observation and an interview with the Administrator, Administrator did not ensure staff complied with the section cited above by not wearing masks which poses a potential Health and Safety and personal rights risk to persons in care.

Ensure hazardous items are locked and not unattended

87309(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above. Cleaning agents and chemicals were found to be accessible to residents. This poses an immediate health, safety or personal rights risk to persons in care.