Follow-up on corrections·March 4, 2024

Citations

6 citations recorded^*CCLD

• 1569.269(a)(6)Type A

  §1569.269 Enumerated rights; severability (a) Residents of RCFE shall have all of the following rights: (6) To care, supervision, & services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement has not been met as evidence by: Based on LPA’s records review and interviews. The facility staff did not ensure that R1 was provided with adequate supervision by locking the back door of the main building blocking R1 from coming inside as well as staff not going to check on R1 every two-three hour as ordered by their physician, which is an immediate risk to the health and safety of residents in care.

• 87465(g)Type A

  Call 9-1-1 for imminent health threats

  87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement has not been met as evidence by: Based on LPA’s records review and interviews. The facility staff failed to call 911 or other medical personnel as the hospice agency after R1 had a fall and changes of conditions, which poses an immediate health and safety risk to residents in care.

• 87411(a)Type B

  Facility personnel sufficiency and competence

  87411 Personnel Requirements (a) Facility personnel shall at all times be sufficient in numbers, & competent to provide the services necessary to meet resident needs...ensure provision of personal assistance & care...This requirement has not been met as evidence by: Based on interviews conducted and records review. Facility staff did not assist R1 with shower & toileting as ordered by their physician supposedly due to their aggressive behavior after R1 came back from hospital, which poses an immediate risk to the health and safety of the residents in care.

• 87464(f)(3)Type B

  87464 Basic Services (f) Basic services shall at a minimum include: (3) Three nutritionally well-balanced meals and snacks made available daily, including low salt or other modified diets prescribed by a doctor as a medical necessity…This requirement has not been met as evidenced by Based on LPA’s observation, records review and interviews with the administrator revealing that facility was not providing meals that meet Recommended Dietary Allowances. This is a potential risk to residents in care.

• 87468.1(a)(2)Type B

  Safe, healthful, comfortable accommodations

  87468.1 Personal Rights of...(a) Residents in all RCFE shall have all of the following personal rights: (2) To be accorded safe, healthful & comfortable accommodations ...This requirement has not been met as evidence by: Based on LPAs observation and record review the facility failed to ensure resident's R1 personal rights where met when R1 was found unattended on the floor wearing only pull-up diaper, which poses a potential health and safety risk to residents in care.

• 87211(a)(1)(B)Type B

  87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require…(1) A written report shall be submitted to the licensing agency & person responsible for the resident within 7 days of the occurrence of any of the events…(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement has not been met as evidence by: Based on LPA’s records review and interviews conducted Administrator did not ensure that CCL was notified of incidents involving R1 after falls. Per hospice records revealed that R1 had incidents of falls and changes of conditions that were not reported to them nor CCL, which poses a potential health & safety risk to residents in care.