Excellence Board and Care Llc

Store centrally held medications in locked secure place

Based on observation, the licensee did not comply with the section cited above medication key was left in file cabinet making medication accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.

Maintain facility in clean, safe, sanitary condition

Based on observation, the licensee did not comply with the section cited above backyard had old furniture, metal, and other debris in backyard which poses/posed a potential health, safety or personal rights risk to persons in care.

Keep bathing and hygiene facilities in operating condition

Based on observation, the licensee did not comply with the section cited above bathroom #3 sink did not work at time of visit which poses/posed a potential health, safety or personal rights risk to persons in care.

Safe, healthful, comfortable accommodations

Based on observation, the licensee did not comply with the section cited above all three residents had cameras in bedrooms 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 LPA observed open alcohol accessible to residents at time of visit which poses/posed a potential health, safety or personal rights risk to persons in care.

Document each PRN medication dose taken

Based on observation and record review, the licensee did not comply with the section cited above PRN medication Trazodone Hyrochlor 50mg Tab for R2 is being given daily with no record of dosage and resident's response and both R1 and R2 was missing their medication sheet for the month of November 2024 which poses/posed a potential health, safety or personal rights risk to persons in care.

Ensure hazardous items are locked and not unattended

Based on observation, the licensee did not comply with the section cited above LPA observed cleaning products stored inside a kitchen cabinet underneath the sink accessible to residents. The cabinet did not have a lock or other safety mechanism in place to prevent access. Cleaning products included (2) powder cleanser (Bar Keepers Friend). Located in the kitchen island cabinet were (2) cleaning sprays Weiman Stainless Steel and an unidentified cleaning solution. The cabinet did not have a lock or safety mechanism. Stored in the pantry cabinet unlocked and accessible to residents was a can of butane fuel (First Street brand). In the unlock laundry area was (2) Clorox and (1) detergent bottle 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 LPA observed resident #1 (R1) with full bed rails and R2 with half bed rails. R1 is not receiving hospice care. Licensee does not a have a note from physician for half bed rails for R2 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 Licensee Rey did not have any documents supporting an Emergency Disaster Drill was completed which poses/posed a potential health, safety or personal rights risk to persons in care.

Assist residents with self-administered medication

Based on observation, interview, and record review, the licensee did not comply with the section cited aboveR1's PM Medication- Temazepam 15 mg QTY 30 (Take 1 capsule by mouth at bedtime) . R1's PM Medication- Temazepam 15 mg QTY 30 (Take 1 capsule by mouth at bedtime) .R2's AM Medication - Eliquis 2.5 MG (Take 1 tablet by mouth every morning and evening) . R2's AM Medication- Senna Plus 50-8,6 MG (Take two tablets by mouth every morning and evening).. R2's AM Medication - Risperidone 0.5 MG ( Take 1 tablet by mouth every morning and evening) November 4th - November 11th 2024 medication was not administered no supporting documents was provided for the reason. R2's Evening Medication - Senna Plus 50-8,6 MG (Take two tablets by mouth every morning and evening) was not administered no supporting documents was provided for the reason which poses an immediate health, safety or personal rights risk to persons in care.

Store centrally held medications in locked secure place

Based on observation, the licensee did not comply with the section cited above LPA observed in the office area a filing cabinet ajar and unlocked contents were residents and staff medication. In staff room #1 the door was unlocked and medication was present and accessible to residents. Located in the dresser in the dining room was a (1) bubble pack of pills Hydroxyzine HCL 25 MG in the drawer which poses an immediate health, safety or personal rights risk to persons in care.

Maintain facility in clean, safe, sanitary condition

Based on observation, the licensee did not comply with the section cited above LPA observed a closet door in resident #1 (R1) room was inoperable. The issue appeared to be caused by significant rust damage to the door track, preventing proper opening and closing. LPA observed in the backyard outside the shed a mattress, shopping cart, television, two (2) dressers, and an unhinged door. On the side of the shed was broken pieces of tile which poses/posed 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 he one (1) half bath in the kitchen water temperature measured at 71.4 degrees f, restroom #4 water temperature measured at 86.7 degrees f., and restroom #9 outside water temperature measured below the 105 degrees f. which poses/posed a potential health, safety or personal rights risk to persons in care.