Fil-am Home for Seniors Ii

(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training... (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the cited section, as one (1) of four (4) staff lacked proof of first aid certification, posing a potential health and safety risk to persons in care.

(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician... who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services... (1) The licensee has received a hospice care waiver from the department.This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the cited section, facility exceeded its hospice waiver capacity (2 approved; 4 on hospice), posing a potential health and safety risk to persons in care.

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication... This requirement is not met as evidenced by:Based on record review, the licensee did not comply with the cited section, as two (2) of four (4) residents had over-the-counter medications without physician orders, posing a potential health risk to persons in care.

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition.. keep the appraisal accurate. This requirement is not met as evidenced by:Based on record review the licensee did not comply with the section cited above in six (6) out of six (6) residents did not have updated re-appraisals which poses/posed a potential health, safety or personal rights risk to persons in care.

c) The medical assessment shall include, but not be limited to:(1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results..(A) Communicable tuberculosis. This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above in six (6) out of six (6) residents did not have TB test on file which poses/posed a potential health, safety or personal rights risk to persons in care.

All personnel, including the licensee and administrator, shall be in good health, and physically capable of performing assigned tasks .... shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician This requiment is not met as evidenced by:Based on record review, the licensee did not comply with the cited section. Three (3) of four (4) staff files lacked TB test results and/or physical examinations, posing a potential health and safety risk to persons in care.

2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports... This training shall be administered on the job, or in a classroom setting, or both, and may include online training.This requiment is not met as evidenced by: Based on record review, the licensee did not comply with the cited section, as three (3) of four (4) staff files lacked required ongoing training documentation, posing a potential health and safety risk to persons in care

Based on record review, the licensee did not comply with the section cited above as the facility has a hospice waiver for only two (2) but currently has four (4) residents on hospice 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 as three (3) out of four (4) staff files did not contain documentation of required ongoing/continuing training which poses a potential health, safety, or personal rights risk to persons in care.

Based on observation the licensee did not comply with the section cited above by kitchen cabinet door lock being broken which poses an immediate 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 four (4) staff/caregivers did not have proof of first aid certification 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. Four (3) out of four (4) staff files did not contain TB test results or physical examinations, 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 six (6) out of six (6) residents did not have updated re-appraisals which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation the licensee did not comply with the section cited above in two (2) out four (4) residents, medication review revealed there were over the counter medications not prescribed by physician 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 one (1) out of six (6) residents file did not contain a current physician’s order authorizing the use of bed rails which poses/posed a potential health, safety or personal rights risk to

Based on record review the licensee did not comply with the section cited above in six (6) out of six (6) residents did not have TB test on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, licensee did not provide proof of liability insurance, the licensee did not comply with the section cited above in 5 out of 5 residents, and/or staff, visitor sand which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, R3 did not have annual medical assessment, the licensee did not comply with the section cited above in 1 out of 5 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, medications were observed in 2 different trays on top of R2's nightstand, the licensee did not comply with the section cited above in 1 out of 5 residents which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review, licensee could not provide documented proof of quarterly drills, the licensee did not comply with the section cited above in 5 out of 5 residents, and/or staff, visitors, which poses/posed a potential health, safety or personal rights risk to persons in care.

Infection Control Requirements (c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1) The Infection Control Plan shall include all of the following: (F)Staff shall demonstrate knowledge of and skill in infection control, as appropriate to the job assigned as evidenced by safe and effective job performance. This standard is not met as evidence by: LPA observed Staff #2 (S-2) not wearing a mask. LPA observed S-2 obtain an N-95 mask shortly after LPA's arrival, however, S-2, was not wearing the N-95 mask correctly as (1) mask strap was hanging under S-2's chin.

Based on observation, sink #1 in resident bathroom was leaking water from hot faucet knob when turned on, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation,backyard contained animal feces throughout the backyard area, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, resident bathroom floor had hair, stains and dirt throughout shower floor, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on records reviewed, the licensee did not comply with the section cited above in 2 out of 4 files reviewed which poses/posed a potential health, safety or personal rights risk to persons in care. S1 and S2 did not have a health screening with proof of a TB clearance on file.