Majintin Ville

Based on records 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.

Based on record review, the licensee did not comply with the section cited above in 1 of 3 residents, which poses a potential personal rights risk to persons in care. LPA Colvin observed that R3's Admissions Agreement is primarily blank, with important information (such as facility information, rate for charges, and services provided) left blank

Based on record review, the licensee did not comply with the section cited above in2 of 3 residents, which poses a potential personal rights risk to persons in care. LPA Colvin observed that R2 & R3 do not have a completed Needs & Services Plan in their file.

Based onrecord review, the licensee did not comply with the section cited above in 1 of 3 residents, which posed a potential health, safety or personal rights risk to persons in care. LPA Colvin observed that R2 did not have a completed Pre-Admission Appraisal in their file.

Based on observation, the licensee did not comply with the section cited above in 1 area of the facility (cabinet under kitchen sink), which poses an immediate health and safety risk to persons in care. LPA Colvin observed numerous cleaning chemicals in the cabinet under the kitchen sink, which was unlocked and accessible.

Based on record review, the licensee did not comply with the section cited above in 1 of 3 residents, which poses an immediate health and safety risk to persons in care. LPA Colvin observed that R1 is bedridden, according to their Physician's Report. Physician's Report additionally indicates that it is a permanent condition.

Based on record review, the licensee did not comply with the section cited above with outstanding Licensing Fees due to the Department, which poses a potential health, safety or personal rights risk to persons in care. LPA Colvin observed that the facility has outstanding Licensing Fees in the amount of $989.

Based on interview, the licensee did not comply with the section cited above in4 of 4 quarterly disaster drills, which poses a potentia safety risk to persons in care. LPA Colvin confirmed with Licensee/Administrator that there are no documented Emergency Disaster Drills for the facility.

Additional Personal Rights of Residents in Privately Operated Facilities: (a) In addition ..for the elderly shall have all of the following personal rights:(8) To be free from neglect, .. or sexual abuse. This requirement was not being met as evidenced by: Based on staff interview, LPA found that R1 was not being afforded baths by staff. This is a potential personal rights risk to residents in care.

Incidental Medical and Dental Care: (a) A plan for incidental medical..shall be developed by each facility. The plan shall encourage routine medical ..provide for assistance in obtaining such care..(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not being met as evidenced by: Based on interview, LPA discovered that staff were not assisting with R1 with receiving their medications nor in administrating them. This is a potential health and safety risk to residents in care.

False Claims: No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met by: Based on observations and record review, the Licensee did not comply with the above regulation with staff training certificates. LPA Colvin observed the facility to be in possession of blank signed training records. This is an immediate safety risk to residents.

Reporting Requirements: (a) Each licensee shall furnish...such reports... including,...:(1) A written report shall be submitted to the licensing agency...within seven days of the occurrence of any of the events... This requirement was not met by: Based on record review, the Licensee did not comply with the above regulation. LPA Colvin observed that no incident reports have been submitted to Licensing since July 2020. This is a potential safety risk for all residents in care.

Hospice Care of Terminally Ill Residents: (f) The licensee shall maintain a record of all hospice-related training provided to the licensee or facility personnel for a period of three years. This record shall be available for review by the Department. This requirement was not met as evidenced by: Based on record review, the Licensee did not comply with the above regulation with at least 2 staff members (S1 & S2). LPA Colvin observed that there was no record of staff training for care of R1's G-Tube, for which R1 was receiving Hospice care for. This was an immediate health risk to R1.

Care of Bedridden Residents: (f) To accept or retain a bedridden person, a facility shall ensure the following: (1) The facility's Plan of Operation includes a statement of how the facility intends to meet the overall health, safety and care needs of bedridden persons. This requitement was not met by: Based on record review, the Licensee did not comply with the above regulation. The facility retained R1, who is bedridden, for almost one year without having a Plan of Operation regarding care of bedridden residents. This was a potential health and safety risk for R1.

Fire Clearance: (a) All facilities shall maintain a fire clearance...Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance... (2) Bedridden persons. This requirement was not met as evidenced by: Based on record review, the Licensee did not comply with the above regulation with one resident (R1). LPA Colvin observed R1 , who is bedridden, lived at the facility for almost 1 year while the facility failed to obtain fire clearance for bedridden residents. This was an immediate safety risk for R1.

Care of Bedridden Residents: (f) To accept or retain a bedridden person, a facility shall ensure the following: (3) Staff records include documentation of staff training specific to Care of Bedridden Residents. This requirement was not met as evidenced by: Based on record review, the Licensee did not comply with the above regulation with at least 2 staff members (S1 & S2). LPA Colvin observed that S1 & S2 do not have required training on care of bedridden residents, yet provided care to R1, who was bedridden. This was an immediate health risk for R1.

Hospice Care of Terminally Ill Residents: (h) For each terminally ill resident receiving hospice services...the licensee shall maintain the following in the resident’s record: (4) A copy of the resident’s current hospice care plan... This requirement was not met as evidenced by: Based on record review, the Licensee did not comply with the above regulation with at least one resident (R1). LPA Colvin observed that there was no Hospice Care Plan on file for R1 in the facility's records. This is a potential health risk for R1.