Chantilly Lace Manor Ii

Based on LPAs observations, the licensee did not comply with the section cited above by staff #3 (S3) did not have a First Aid/CPR certification on file; which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPAs observations, the licensee did not comply with the section cited above by staff#1(S1) and staff#3 (S3) did not have a health screening with tuberculosis results on file. Staff#2 (S2) did not have a health screening on file; which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPAs observations the licensee did not comply with the section cited above by Resident #1 (R1) and Resident #2 (R2) medication records were not accurately maintained by staff when compared to medication given; which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPAs observations, the licensee did not comply with the section cited above by the facility does not have enough emergency food and water for 72 hour emergency. which poses/posed a potential health, safety or personal rights risk to persons in care.

87506 Resident Records(d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours...this requirement is not met as evidence by: The Licensee did not comply with the section cited above by LPAs not having access to residents files which contain admissions agreement and physician's reports and resident registry during visit. Staff stated they did not have access to the files; which is a potential health, safety and personal rights risk to persons in care.

Based on LPA observations; the licensee did not comply with the section cited above by fill-in staff was not sure of facility's medication record management; which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA observations, the licensee did not comply with the section cited above by not maintaining a medication administration record/log; which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPA observations, the licensee did not comply with the section cited above by having cameras in resident's bedrooms; which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA observation, the licensee did not comply with the section cited above by authorized persons signatures missing on R1's admissions agreement documents; which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA record review, the licensee did not comply with the section cited above by not maintaining a physical health record for S1, S2, S3 for review; which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA observations, the licensee did not comply with the section cited above by storing facility supplies in resident's private closet; which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation and interview, the licensee did not comply with the section cited above by storing expired medication and accepting medication with altered labels which poses a potential health, safety or personal rights risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above in submitting a complete Infection Control Plan which poses a potential health, safety or personal rights risk to persons in care.

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement was not met as evidenced by:LPAs inspected resident medications and centralized record and found three medications not listed on the centralized record. Two of three medications appeared to have been administered, which poses a potential health and safety risk to clients in care.

Based on observation, interview and record review, the licensee did not comply with the section cited above in maintaining a complete Emergency Disaster Plan which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in not maintaining a log for two different PRN medications for two different residents which poses a potential health, safety or personal rights risk to persons in care.

87411 Personnel Requirements - General (c)(1)&(f)Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.(f) all personnel, including the licensee and administrator , shall be in good health... This requirement was not met as evidenced by:Based on file review, the Licensee did not ensure that all employees file has proof of first aide training and TB test, which poses a potential health, safety, personal rights violations to persons in care.