At Haven Home Ii

Based on observation of staff records , the licensee did not comply with the section cited above in 1 out of 2, Staff 2 records did not have mentioned trainings, 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 in 1 out of 2 staff files did not have up to date fFirst Aid/CPR training which poses/posed a potential 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 did not have absentee notification plan, which poses/posed a potential health, safety or personal rights risk to persons in care.

87615 Prohibited Health Conditions(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly:LPAs observation of Home health records dated 11/07/24 stating the heel wound is an unstageable pressure ulcer and an exception to retain a prohibited condition was not submitted. If not corrected, the violation will have a direct and immediate risk to the health, safety, or personal rights of clients in care.

Regular observation and documentation of resident changes

87466 Observation of the ResidentThe licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as...a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidenced by LPAs observation of records review of incident report dated 09/20/24 stating the heel wound was a small blister and Home Health records dated 11/07/24 stating R1's wound is an unstageable pressure ulcer. Interviews with staff state they did not observe or care for R1's heel wound because they are not nurses and home health services are being received. An immediate civil penalty in the amount of $500 is hereby assessed. If not corrected, the violation will have a direct and immediate risk to the health, safety, or personal rights of clients in care.

Provide resident hot water for personal care

Based on observation the licensee did not comply with the section cited above in 3 out of approx 13 water access points 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 in 3 out of 11 residents which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above which poses a potential 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 in 1 out of 11 residents 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 in 4 out of 11 resident records which poses 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 which poses a potential 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 in 2 out of 6 staff records, 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, which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in 1 out of 11 residents which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above which poses 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, which poses an immediate health, safety or personal rights risk to persons in care.

Minimum appraisal documentation requirements

87457 Pre-Admission Appraisal - General(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462 Social Factors. This requirement was not met as evidenced by LPAs observation of resident's file. No pre appraisal or needs and service plan was obtained at the time of admission and not observed in file.

Maintain facility in clean, safe, sanitary condition

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by LPA observation of Room 10 observed with hole behind door in need of repair. Clutter in garage in need of removal. Refrigerator in garage in need of cleaning/repair. Hood vent observed open and in need of repair under kitchen cupboard. Bottom kitchen cupboard door broken and in need of repair/replacement.Front door observed broken and not properly latching. This poses a potential health safety and or personal rights risk to residents in care.

Store centrally held medications in locked secure place

87465 Incidental Medical and Dental Care...(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidence by: LPA observation of medications observed unlocked/accessible in kitchen cupboard, kitchen refrigerator, in R6 closet and hallway cupboard. This poses an immediate health, safety and or personal rights risk to residents in care.

Freedom to leave and not be locked in

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department. This requirement was not met as evidence by LPA observation of R1's window observed locked with board preventing from opening R1's exit door observed blocked with chair preventing from exiting. Front door observed with lock at bottom of door.

Based on observation, interview, & record review, 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 reviewed staff files were did not have current training for specialized care needs.

Address and clearance obligations before facility work

Based on observation, interview, & 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. LPA reviewed LIS personnel report which did not have S1, S2, or S3 listed on the reports. S1, S2, & S3 are not associated with the current facility.

Resident access to hazardous items with safety review

Based on observation & interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. In an unlocked cabinet in the kitchen LPA observed medication for R1.

Maintain facility in clean, safe, sanitary condition

Based on observation, 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. LPA observed mold in resident's shower and mildew/mild ring in various toilets.

Based on observation, interview, & record review, 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 reviewed staff files were did not have 20 hours of annual training.

Store disinfectants separately from food supplies

Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. In an unlocked kitchen drawer LPA observed a screw driver & hammer. I cabinet LPA observed degrease spray.

Provide resident hot water for personal care

Based on observation & interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA tested various facets throughout the facility which did not reach at least 105 degrees.

Assist PRN administration when symptoms unclear

Based on observation, interview, record review, 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.

Assist residents with self-administered medication

87465(a)(4) Incidental Medical and DentalCare (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the followng:(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as eivdence by: LPA observation of medication logs, lists and hospital discharge paperwork. Records reviewed showed that the medication were not logged as given/given (2/2022 and 3/2022). This posses an immediate health and safety risk to resident(s) in care.

Maintain facility in clean, safe, sanitary condition

87303 Maintenance and Operation(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by: LPA interviews and observation of the phone service not working properly, fire box alarm bieng overridden and doorbell not funtioning properly.

87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement was not met as evidence by: interviews and observation. LPA conducted interviews that disclosed R1 needs a higher level of care. Records review were observed without a pre-assessment appraisal completed by facility prior to R1's move in. This posess a potential Health and Safety risk to residents in care.

Regular representative updates on care

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. This requirement was not met as evidence by: interviews and observation. Interview conducted showed R1 has a POA that was not notified of R1's move. Records observed showed R1's file did not have an Admission Agreement signed by POA. This posess a potential Health and Safety risk to residents in care.

87307 Personal Accommodations and Services (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident...(A) A bed for each resident... bed shall be equipped with good springs, a clean and comfortable mattress, available pillow(s) and lightweight warm bedding... This requirement was not met as evidence by: LPA observation and interviews conducted. Staff/RP indicated R1 was using a foam mattress on the floor to sleep. LPA observed foam mattress. This poses a potential health and safety risk to residents in care.

87555 General Food Service Requirements(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement was not met as evidence by LPA observation and interviews conducted. LPA observed food source and interviews disclosed that the menu is unable to be followed due to insufficient food source. Facility does not have a 7 day supply of non-perishable and 2-day perishable supply of food to follow menu in place for residents. This poses a potential health and safety risk to residents in care.