Madison Guest Home

(5)... Assistance with self-administered medications shall be limited to the following: (A) Medications usually prescribed for self-administration which have been authorized by the person's physician.This requirement is not met as evidenced by: Based on observation and staff interview, the licensee did not comply with the section cited above as there is no authorization from R1’s physician for one their prescribed medications and the medication remains with R1’s centrally stored medication.

(2)... training requirements shall... include... 20 hours annually, eight hours of which shall be dementia care training... and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care...This requirement is not met as evidenced by: Based on observation and staff interview, the licensee did not comply with the section cited above as staff files did not include 20 hours of annual training conducted, which poses a potential health, safety and personal rights risk to persons in care.

(c) A facility shall conduct a drill at least quarterly for each shift... Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.This requirement is not met as evidenced by: Based on observation and staff interview, the licensee did not comply with the section cited above as emergency drills are currently not being conducted, which poses a potential safety risk to persons in care.

(2)... Hot water temperature controls shall be maintained to automatically regulate the temperature... to attain a temperature of not less than 105 degree F... and not more than 120 degree F (49 degrees C).This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above as water temperature tested at 131.0 degrees Fahrenheit which poses a potential safety risk to persons in care.

(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal...This requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply with the section cited above as resident files reviewed did not include an updated pre-admission appraisal, which poses a potential health, safety and personal rights risk to persons in care.

Based on observation and staff interview, the licensee did not comply with the section cited above as emergency drills are currently not being conducted, which poses a potential safety risk to persons in care.

Based on observation and staff interview, the licensee did not comply with the section cited above as staff files reviewed did not include 20 hours of annual training conducted, which poses a potential health, safety and personal rights risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above as three of three resident files reviewed did not include a pre-admission appraisal, which poses a potential health, safety and personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above as water temperature tested between 138.3 and 152.6 degrees Fahrenheit, which poses a potential safety risk to persons in care.

Based on observation and interview, the licensee did not comply with the section cited above as there is no authorization from a resident's physician for one of their prescribed medications, which poses an immediate health, safety and personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above as medication requiring refrigeration was observed to be accessible to all facility residents in the kitchen fridge, which poses an immediate health, safety and personal rights risk to persons in care.

Based on observation and staff interview, the licensee did not comply with the section cited above as medication for residents is being pre-poured into a plastic weekly medication organizer three days in advance, which poses a potential health, safety and personal rights risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above as two of three resident files reviewed did not include an updated pre-admission appraisal, which poses a potential health, safety and personal rights risk to persons in care.

Hospice Care of Terminally Ill Residents-A current and complete hospice care plan shall be maintained in the facility for each hospice resident.Licensee failed to have a current and complete hospice care plan for R2.

Prohibited Health Conditions-Persons who require Gastrostomy tubes shall not be admitted or retained in a residential care facility for the elderly.This requirement was not met as evidenced by: On 7/29/21 the Department denied exceptions for R1 and R2 to have Gastrostomy tubes. The Licensee failed to relocate R1 and R2 after the Department's denial. Both residents were present at the facility on today's date.