Routine inspection·September 5, 2023

Citations

14 citations recorded^*CCLD

• 87465(f)(1)(2)(3)Type B

  Based on record review, 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. Resident 1 (R1) had blank Identification and Emergency Information form (LIC 601).

• 87459(a)Type B

  Based on record review, the licensee did not comply with the section cited above in 6 out 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care. All 6 residents did not have a Functional Capabilities form (LIC 9172) in their file

• 87208(a)(7)(A)Type B

  Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. There is a caregiver's bed and belogings in an area in the facility that is labeled as an "Open Area" on the facility floor plan sketch. This area should not be use as a caregiver sleeping or living area.

• 87608(a)(3)Type B

  Maintain physician order documentation in resident record

  Based on record review, the licensee did not comply with the section cited above in 5 out 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care. Resident 1 (R1) through Resident 5 (R5) all had a bed rail and LPA did not observe a doctor's order for the bed rails on file. The staff could not find the orders either.

• 87465(a)(4)Type A

  Assist residents with self-administered medication

  Based on observation and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. During medication review, LPA observed discrepencies in Resident 1 (R1), Resident 2 (R2), and Resident 3 (R3). There were empty medication containers/bubble packs, some bubble packs were full even though it is the 5th of the month, some bubble packs had more than 5 pills missing, pills were taken out of the bubble pack in an out of order way (dates are on the bubble pack for each pill) which made it difficult to verify if residents are getting their medication daily, and staff stated for some residents medication was discontinued, but medication is still in their basket. LPA is unable to determine if medication is being given as prescribed because staff could not provide an explaination for some of the discrepencies, did not have a list with all the medicaiton for each resident written by a doctor, and there was no doctor's discontinuation orders for the medication that staff claimed where discontinued.

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• 87465(h)(2)Type A

  Store centrally held medications in locked secure place

  Based on observation and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. Resident 6 (R6) has medication unlocked in the bedroom. R6's Physician Report states that R6 can manage own medication, but R6 shares the bedroom with Resident 5 (R5) and R5's physician report states that R5 cannot manage own medication. Therefore, medication needs to be locked for the safety of Resident 5.

• 87465(c)(1)Type A

  Require physician-written PRN medication directions

  Based on record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. During the visit, staff were unable to provide the LPA with a current/updated medication list for all residents written by the residents' physician. Due to this and not having a Medication Administration Record (MAR), the LPA could not verify if residents had all their medication at the facility and which medications were discontinued.

• 1569.605Type B

  Based on record review, 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. During the visit, the staff could not provide the LPA with a copy of the liability insurance.

• 87412(a)Type B

  Maintain required personnel records for staff

  Based on record review, 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. During the visit, the staff did not know the whereabouts of all staff files and therefore LPA was unable to review any staff files.

• 87457(c)Type B

  Complete admission suitability appraisal

  Based on record review, 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. Resident 5 (R5) did not have a Resident Appraisal (LIC 603A) on file during the visit.

• 87458(a)Type B

  Obtain baseline medical assessment before resident admission

  Based on record review, the licensee did not comply with the section cited above in 2 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care. Resident 1 (R1)'s Physician Report (LIC 602) did not have a physician's signature and Resident 2 (R2) had a blank Physician Report (LIC 602) on file.

• 87458(b)(1)Type B

  Based on record review, 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. Resident 1 (R1)'s Physician Report (LIC 602) did not have a TB exam results.

• 87608(a)(5)(B)Type B

  Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care. Resident 3 and Resident 4 are not hospice and have a full bed rail.

• 87468(c)(2)(A)Type B

  RCFE complaint poster posting requirements

  Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA did not observe the Complaint Poster (PUB 475) posted at the facility.