Mainline Home Care

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. During a medication review, one resident did not have the correct dosage in one of their medication which poses/posed a potential health, safety or personal rights risk to persons in care.

Store centrally held medications in locked secure place

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:Based on observation, licensee did not comply with the regulation noted above. It was observed that 3 medications were stored in the kitchen refrigerator. This poses an immediate health and safety

Fire approval and staff access to unlock systems

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.This requirement is not met as evidenced by: Based on observation, licensee did not comply with the regulation noted above. During inspection of one bathroom, LPA observed cleaning supplies on the floor and on top of the toilet seat cover. This poses an immediate health and safety

Facility must clear fire safety for nonambulatory persons

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal... (1) Nonambulatory persons.This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the regulation noted above. It was discovered that the room fire cleared as "staff" room on the facility sketch is being used as a resident room by non-ambulatory resident during this visit. This poses an immediate health and safety risk to residents in care.

87616 Exceptions for Health Conditions: (a) ... the licensee may submit a written exception request if he/she agrees that the resident has a prohibited and/or restrictive health condition but believes that the intent of the law can be met through alternative means.This is not met as evidenced by: Based on interviews and record review the Licensee did not ensure that a written request for an exception was sent to the Department for approval as soon as R1 started using a catheter. This poses an immediate, health, safety, and personal rights risks to persons in care.

Conformance with applicable laws and regulations

(d) The administrator shall have...(2) Knowledge of and ability to conform to the applicable laws, rules and regulations.This is not met as evidenced by: Based on interview and record review, the licensee did not ensure that the facility obtained an exception request for R1's indwelling catheter as soon as R1 started using catheter.