St Matthews Home for the Elderly Ii

Based on record review, licensee did not send the above information for R1,R2, and R2, the licensee did not comply with the section cited above in 3 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the facility is only approved for 2 hospice residents, however, the facility is providing care for 3 hospice residents, the licensee did not comply with the section cited above in 1 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, R3 & R4 roomates did not sign above acknowledgment, the licensee did not comply with the section cited above in 4 out of 6 residents 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 6 out of 6 residents, staff, and/or visitors, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, S2 did not have personnel file at the facility which documents criminal clearance, the licensee did not comply with the section cited above in 6 out of 6 residents 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 6 out of 6 residents, which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, interview, and record review, the licensee did not comply with the section cited above in making available staff records for 3 of 5 staff, which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, interview, and record review, the licensee did not comply with the section cited above in submitting a change of facility sketch for the room proposed for staff use, which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, interview, and record review, the licensee did not comply with the section cited above in 2 staff not being associated to the facility, which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above in having the administrator being present at the facility during normal working hours, which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above in 2 available staff files reviewed did not have proof of required staff training and orientation, which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, interview, and record review, the licensee did not comply with the section cited above in maintaining proof of a current and valid adminstrator certificate available at the facility, which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above in 2 avilable staff files did not have health screenings, which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, interview, and record review, the licensee did not comply with the section cited above in 3 of 5 staff files were not maintained on the administrator and 2 staff, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above in providing licensing with a copy of their current and valid liability insurance information, which poses a potential health, safety or personal rights risk to persons in care.

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in insufficient 2-day perishables for 6 of residents, which poses an immediate health, safety or personal rights risk to persons in care.

Based on [(observation) (interview) (record review)], the licensee was requested to submit an infection control plan to the licensing agency by 7/28/23 and has yet to receive it, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in a staff room has been created inside a resident room, which poses an immediate health, safety or personal rights risk to persons in care.

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in 2 knoves and a pair of scissors were found in a drawer in the kitchen accessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.

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

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

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [6 of 6 residents not having complete files, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in1 of 6 residents do not have an admissions agreement on file, which poses a potential health, safety or personal rights risk to persons in care.

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in 3 residents not having a written order for bedrails indicating the need for it, which poses a potential health, safety or personal rights risk to persons in care.

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in 3 residents in care on hospice and facility only has approval for 2, which poses/posed a potential health, safety or personal rights risk to persons in care.

87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This requirement is not met as evidence by: Based on observation licensee did not ensure staff did not wear mask properly as observed on visit conducted on 11/3/22 which poses an immediate risk to the health, safety, personal rights to the persons in care.

87411 Personnel Requirements - General:(c) All RCFE...(6)The licensee shall maintain documentation pertaining to staff training in the personnel records, ... For on-the-job training,..This requirement is not met as evidence by: Based on document review and observation licensee failed to ensure staff #1 and #2 files were available for review during the visit conducted on 11/3/23 and to provide documents after which poses a potenital risk to the health, safety, personal rights of the persons in care.

(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:This requirement is not met as evidence by: Based on observation Licensee did not ensure personnel records are available at the facility for licensing agency to review fjor all staff which poses a potential health, safety, or personal rights risk to the persons in care.

Based on observation, interview, and record review, the licensee did not comply with the section cited above as LPA discovered that the facility has an approved hospice waiver for 2, but currently has 4 residents on hospice, which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, interview, and record review, the licensee did not comply with the section cited aboveas LPA observed 3 of 6 resident files to be missing required documentation, which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, interview, and record review, the licensee did not comply with the section cited above in 3 of 3 staff files being incomplete, which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, interview, and record review, the licensee did not comply with the section cited above in 3 of 3 staff working at the facility were present without being associated to the facility, which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation and interview, the licensee did not comply with the section cited above when LPA observed the toilet in bathroom# 2 was not in good repair as it was missing the toilet seat and top pump cover, which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, interview, and record review, the licensee did not comply with the section cited above in 2 of 6 residents with dementia did not have an updated medical assessment or reappraisal in their file, which poses a potential health, safety or personal rights risk to persons in care.