Mama Angelina Coconocho

Based on record review and interview, the licensee did not comply with the section cited above in one out of four staff which poses/posed a potential health, safety or personal rights risk to persons in care.

FIRE SAFETY: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met, as evidenced by: Based on observation, the Licensee did not ensure the facility was maintained in conformity with the regulations adopted by the State Fire Marshal. The LPA observed a lock on the exterior gate. No secondary exit was available. This posed an immediate threat to the health and safety of the residents in care.

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 & locked place that isn't accessible to persons other than employees responsible for the supervision of the medication. This requirement was not met, as evidenced by: Based on observation, the Licensee did not ensure refrigerated medications were kept in a safe & locked place. LPA observed medications in the facility's refrigerator. The medications were not maintained secured from any unauthorized individuals.

FIRE CLEARANCE: (a) All facilities shall maintain a fire clearance approved by... the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the...licensee shall...obtain an appropriate fire clearance approved by...the State Fire Marshal. (2) Bedridden persons. This requirement was not met, as evidenced by: Based on records, the Licensee didn't ensure an appropriate fire clearance was obtained prior to accepting a bedridden person into care. R3's Physician's Report noted R3 is non-ambulatory & bedridden. R3 was unable to reposition themself in bed.

Care of Persons with Dementia: (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(5) Each resident with dementia shall have an annual medical assessment...and a reappraisal done at least annually... This requirement was not met as evidenced by: Based on record review, the Licensee did not comply with the above regulation with at least on resident. LPA Colvin observed that R1's most recent Physician's Report is dated 6/11/21. R1 is diagnosed with Dementia. This is a potential health and safety risk to R1.

Care of Persons with Dementia: (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement was not met as evidenced by: Based on observation, the Licensee did not comply with the above regulation with two exit doors. LPA Colvin observed both the front door and back door of the facility to have their auditory alarms turned off. LPA Colvin also tested the doors to confirm. This is an immediate safety risk to Dementia residents.

Personal Accommodations and Services: (a) Living accommodations...shall be related to the facility's function...The following provisions shall apply: (3) Equipment and supplies necessary...licensee shall assure provision of: (B) Bedroom furniture, which shall include, for each resident...a lamp, or lights sufficient for reading... This requirement was not met by: Based on observation, the License did not comply with the above regulation with one resident. LPA Colvin observed no operational light source in R1's room other than the bedroom window. This is a potential personal rights violation of R1.

Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met as evidenced by: Based on observations, the Licensee did not comply with the above regulation with at least one area of the facility. LPA Colvin observed that the front door was locked with a deadbolt that is only able to be unlocked with a key. This is an immediate safety risk to residents in care.

Reporting Requirements: (a) Each licensee shall furnish...reports...including... the following: (1) A written report shall be submitted ...within seven days of...(D) Any incident which threatens the welfare, safety or health of any resident, such as... unexplained absence of any resident. This was not met by: Based on record review, the Licensee did not comply with the above regulation with at least one occurance. LPA Colvin confirmed that no report was submitted for R1's elopment from the facility on 7/4/22. This is an immediate safety risk of all residents, as the facility has never submitted a report to Licensing.

Personal Rights of Residents in All Facilities: (a) Residents...have all of the following personal rights: (11) To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours... This requirement was not met as evidenced by: Based on observations, the Licensee did not comply with the above regulation. LPA Colvin observed Visitor Hours posted outside the facility which were unreasonably restrictive. Additionally, the posted hours are not what is reflected in the facility's Admissions Agreement. This is a potential personal rights violation of all residents.

Based on LPA Gardner's observation of unlocked medication left on the counter, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.