Hepzebah House

Based on interview, the licensee did not comply with the section cited above by failing to obtain/maintain liability insurance as required, which poses a potential health, safety, and personal rights risk to persons in care.

Based on interview, the licensee did not comply with the section cited above by failing to obtain/maintain liability insurance as required which poses a potential health, safety, and personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above. Resident records were incomplete and or missing documents, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on interviews, the licensee failed to ensure that the administrator had knowledge of licensing rules and regulations which poses an immediate health and safety risk to the residents in care.

Based on record review, the licensee did not comply with the section cited above. Upon LPA's request Licensee/Administrator was unable to provide S1's facility records. LPA was informed that S1 got hired on 01/15/2024 and no file was completed. This 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 cited above to ensure that CSMDR were properly documented for accountability. R1’s medication was not documented properly. This poses an immediate health and safety risk to residents in care.

Based on observation, interview, and record review, the licensee did not comply with the section cited above in two out of two incidents reports for R4 were not submitted to the department which poses/posed a potential health, safety or personal rights risk to persons in care.

87506 Resident Records: (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident...This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above. Resident records were incomplete and or missing documents, which poses/posed a potential health, safety or personal rights risk to persons in care.

87412 Personnel Records: (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above. Upon LPA's request Licensee/Administrator was unable to provide S1's facility records. LPA was informed that S1 got hired in Fabruary 2023 and no file was completed. This poses/posed a potential health, safety or personal rights risk to persons in care.

87506 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 requirement was not met as evidenced by: Based on record review and interviews, the licensee did not comply with the section ctied above in at least 1 resident which poses a potential Health, Safety, or Personal Rights risk to persons in care.

87457 Pre-Admission Appraisal - General (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needsThis requirement was not met as evidenced by: Based on record review and interviews, the licensee did not comply with the section ctied above in 1 out of 5 residents which poses a potential Health, Safety, or Personal Rights risk to persons in care.

87458 Medical Assessment (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.This requirement is not met as evidence by: Based on records review, R1, R2, and R3 did not have Physician Reports or medical assesments in their facility files. This poses a potential health and safety risk to residents in care.

87355 Criminal Record Clearance (a) The Department shall conduct a criminal record review of all individuals... and shall have the authority to approve or deny a facility license, or employment, residence, or presence in the facility, based upon the results of such review.This requirement is not met as evidence by: Based on LPA observations and interviews, the individual providing supervision to residents in care did not submit a criminal background clearance to the department. This poses an immediate health and safety risk to residents in care.

87463 Reappraisals (c) The licensee shall arrange a meeting with the resident... when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first.This requirement is not met as evidenced by: Based on records review, R1, R2, and R3 did not have reappraisails in their facility files.This poses a potential health and safety risk to residents in care.