Follow-up·January 27, 2022

Citations

4 citations recorded^*CCLD

• 87211(a)(D)Type B

  87211 Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(D) Any incident which threatens the welfare, safety or health of any resident...This requirement is not met as evidence by: During LPA's interview conducted with administrator and police officer. Administrator did not submit and incident report to LPA regarding R1's incident that took place prior to visit.This posses a potential health and safety risk to residents in care.

• 87405(a)Type B

  Certified administrator requirements and substitute coverage

  87405Administrator - Qualifications and Duties(a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities ..This requirement is not met as evidence by: Based on observation and record reviews the Administrator Miriam Rudes did not have a current Administrator Certificate or an Administrator wavier on file.This poses a potential health and safety risk to residents in care.

• 87411(3)(c)Type B

  87411 Personnel Requirements - General(3) The training shall include, but not be limited to, the following: (c) All RCFE staff who assist residents with personal activities of daily living shall receive at least ten hours of initial training within the first four weeks of employment and at least four hours annually thereafter.This requirement is not met as evidence by: Based on observation LPA did not observed current training records for Staff #1-2. This possess a potential health and safety risk to residents in care.This posses a potential health and safety risk to residents in care.

• 87608(a)(3)Type B

  Maintain physician order documentation in resident record

  87608 Postural Supports(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance.. 3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record...This requirement is not met as evidence by: LPA observed bed rails on R#2's bed. LPA reviewed residents files and did not see an exception for R2 to have bed rails.This poses a potential health and safety risk to residents in care.