Shiloh Retreat

Based on record review the licensee did not comply with the section cited above due to four (4) of (4) staff files did not show documented staff training (staff attending training, topics, hours and dates) which poses/posed a potential health, safety or personal rights risks 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 is not met as evidenced by: Based on interviews, records review, the Administrator did not comply with the section cited above in which the staff failed to sign the Medication Administration Record (MAR) on the correct date, and omissions in signing the MAR altogether for R1-R2 which poses a potential health, safety or personal rights risk to residents in care.

87465 Incidental Medical and Dental Care(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.This requirement is not met as evidenced by: Based on interview, records review, the Administrator did not comply with the section cited above in which staff missed medications in the blister packs and medications that were dropped and replaced with doses from the following day's blister pack without proper documentation for R1-R2 which poses an immediate health, safety or personal rights risk to residents 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 is not met as evidenced by: Based on interviews, records review, the Administrator did not comply with the section cited above in which the staff failed to sign the Medication Administration Record (MAR) on the correct date, and omissions in signing the MAR altogether for R1-R2 which poses an immediate health, safety or personal rights risk to residents in care.

87465 Incidental Medical and Dental Care..(h) The following requirements shall apply to medications which are centrally stored:(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.This requirement is not met as evidenced by: Based on interviews, records review, the Administrator did not comply with the section cited above in which there were instances of pre-pouring medications prior to administration for R1-R2 which poses an immediate health, safety or personal rights risk to residents in care

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: (1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.This requirement is not met as evidenced by: Administrator did not comply with the section cited above in which the Administrator did not submit an incident report regarding multiple medication administration discrepancies for R1-R2 which poses a potential health, safety or personal rights risk to residents in care.

Admission Agreements 1569.652 Refund conditions.(c)A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued...to entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed. This requirement not met as evidence by: Based on interviews and record review, licensee failed to refundR1's monies with 15 days after R1's belonging were removed and after R1's death.

Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility...: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.This requirement is not met as evidenced by: Based on interviews and documents reviewed licensee did not ensure R1 was provided medical care in a timely manner after developing a Stage 4 pressure wound which poses an immediate risk to the persons health, safety, or personal rights of the persons in care.

Based on interview, the licensee did not comply with the section cited above in [count] out of 2 out of 5 clients, because the facility currently has a hospice waiver approved for 2 residents, however there are currently 4 residents whoare on hospice, which poses a potential health, safety or personal rights risk to persons in care.