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Based on records review, the licensee did not comply with the section cited above. The only staff on shift at the time of LPA's visit did not have current first aid/CPR certification which posed a potential health, safety or personal rights risk to persons in care.

Based on interview and record review, the licensee did not comply with the section cited above in [4] out of [4] residents receiveing hospice services. This poses a potential health, safety and 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 [4] residents who did not have a complete medical assessment on file. The medical assessment for R1 was missing information on the resident's TB test results, R2's report was missing information on their ambulatory status, R4 & R5's report was missing the TB test information. This poses a potential health, safety and personal rights risk to persons in care.

REPORTING REQUIREMENTS: Each licensee shall furnish to the licensing agency such reports as the Department may require, including...: A written report shall be submitted to the licensing agency... within 7 days of the occurrence of any of the events specified in (A) - (D) below....Any incident which threatens the welfare, safety or health of any resident, such as...unexplained absence of any resident. This requirement was not met, as evidenced by: Based on interviews, the Licensee did not ensure any appropriate agency was contacted in order to cross report the neglect of R1.