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Document each PRN medication dose taken

Based on observation, the licensee did not comply with the section cited above as Resident 2 and 3 were missing PRN medications that were listed in their medication list, additionally Resident 2 had PRN medications that have been used and are not listed on current physician medication list, which poses an immediate health, safety or personal rights risk to persons in care.

Update reappraisal at required intervals

Based on record review, the licensee did not comply with the section cited above Resident # 1's last dated Appraisal is dated 2/29/24 and has not been done for the 2025 year and Resident #2's Appraisal is not dated, which poses a potential health, safety or personal rights risk to persons in care.

Provide resident hot water for personal care

Based on observation, the licensee did not comply with the section cited above as during visit LPA tested the water temperature in all bathrooms and the water was below the range measuring between 90.8-100.8 degrees F, which poses a potential health, safety or personal rights risk to persons in care.

Keep prescriptions in original containers

Based on observation during medication review, the licensee did not comply with the section cited above as there there was a pill box dated Sun-Sat that per converstation with Administrator is being used for medications, med box had medication in the Wed/Thurs slots, which poses an immediate health, safety or personal rights risk to persons in care.

Obtain baseline medical assessment before resident admission

Based on record review, the licensee did not comply with the section cited above as Resident # 2's last complete physician report is dated 8/15/24 and there is no idications stating that resident has refused any visits with physician, therefore, the yearly physician report has not been completed, which poses a potential health, safety or personal rights risk to persons in care.

Include required health screening documents

Based on record review, the licensee did not comply with the section cited above as Staff #2's file was missing the required health screening report and TB result, which poses a potential health, safety or personal rights risk to persons in care.

Limit operations to licensed capacity

Based on observation and record review, the licensee did not comply with the section cited above as Resident #1 is currently residing in Room #3, per physician report resident is Non-Ambulatory and the only room licensed for Non-Ambulatory is Room #1 (this room is currently occupied by Administrator as she lives in facility), this poses a potential health, safety or personal rights risk to persons in care.