Routine inspection·May 17, 2023

Citations

9 citations recorded^*CCLD

• 87412(a)Type B

  Maintain required personnel records for staff

  Based on observation and interviews with staff, the licensee did not comply with the section cited above, there was no personnell records avialable for review, which poses a potential health, safety or personal rights risk to persons in care.

• 1569.695(c)Type B

  Based on interviews and record reviews, the licensee did not comply with the section cited above in that the facility is not conducting emergency disaster or fire drills and/or there is no documentation of drills being conducted, which poses a potential health, safety or personal rights risk to persons in care.

• 1569.695(f)Type A

  Based on observation and interviews with staff, the licensee did not comply with the section cited above in that the facility has been placing poles in the sliding glass doors in a residents bedroom and in the back of the house rendering them inoperable to staff and emergency personnel, which poses an immediate health, safety or personal rights risk to persons in care.

• 87207(a)Type A

  Based on observations, the licensee did not comply with the section cited above in that the handle on the fire door for the hall leading to resident bedrooms the handle is reversed so that the lock is outside, inaccessible to residents. There is also a wedge next to the fire door for proping the door open which poses an immediate health, safety or personal rights risk to persons in care.

• 87458(b)(1)Type B

  Based on a record review, the licensee did not comply with the section cited above in that R1 is missing a TB test clearance on file, which poses/posed a potential health, safety or personal rights risk to persons in care.

• 87506(b)Type B

  Resident record must include minimum required items

  Based on records reviews, the licensee did not comply with the section cited above in resident files -R1 needs single sided admission agreement, R1 & R2 need the facility representative needs to sign the admission agreement, All 3 residents missing a signed peronal rights form and safeguard for personal property, R3 missing emergency ID, which poses a potential health, safety or personal rights risk to persons in care.

• 87555(a)Type A

  Diet quality and preparation in safe healthful manner

  Based on observations, the licensee did not comply with the section cited above in that the facility's 2-day perishable and 7-day non-perishable food supply is insufficient (photos taken and detail of observation on LIC812) and spoiled food was observed in the cabinet, which poses an immediate health, safety or personal rights risk to persons in care.

• 87705(c)Type B

  Based on observations the licensee did not comply with the section cited above in that there were a number of items either missing or not safe guarded as required for residents with dementia (knives accessible, stove range accessible, out-dated MD report, exits not alarmed, etc.), which poses/posed a potential health, safety or personal rights risk to persons in care.

• 87608(a)Type B

  Based on observation and record review, the licensee did not comply with the section cited above in that R3 is using half bedrails as postural supports but there are no physician orders on file, which poses/posed a potential health, safety or personal rights risk to persons in care.