St. Joseph's Guest Home

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. Based on record review, the licensee did not comply with the section cited above in 2 out of 4 quarterly fire drills were not maintained which posed a potential safety risk to persons in care.

Kitchen sanitation against contamination sources

Based on observation, the licensee did not comply with the section cited above in 1 out of 1 cockroaches were found in the kitchen area which posed a potential personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in 2 out of 4 quarterly fire drills were not maintained which posed a potential safety risk to persons in care.

Facility must clear fire safety for nonambulatory persons

Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 2 residents were not cleared to reside in an ambulatory room which posed an immediate safety risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in 1 out of 1 staff training records were not on file which posed a potential 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 1 staff did not obtain their medication training after a citation on 04/15/2024 was issued which posed a potential health, risk to persons in care.

Maintain required personnel records for staff

Based on record review, the licensee did not comply with the section cited above in 1 out of 1 staff records were not complete which posed a potential personal rights risk to persons in care.

Authorized physician-prescribed self-administered meds

Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 3 resident's were not provided medication as prescribed which posed an immediate health risk to person in care.

Obtain baseline medical assessment before resident admission

Based on records reviewed, the licensee did not comply with the section cited above in 2 out of 3 residents did not have their Physician's Report updated within the last year which posed a potential health risk to persons in care.

Maintain separate complete record for each resident

87506(a) Resident Records The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.… this requirement was not met as evidenced by: Based on records review, the Licensee did not have a resident record for R1 at the facility. This posed a potential health risk to one of three residents in care.

3-4200 Facility Evaluation Buildings and Grounds - No fence or approved cover for bodies of water; broken window glass in accessible areas; exposed live electrical wires; .… this requirement was not met as evidenced by: Based on observation the facility had exposed electrical wires. This posed a potential health risk to three of three residents in care.

87211(a)(1)(d) Reporting Requirements Any incident which threatens the welfare, safety or health of any resident, … this requirement was not met as evidenced by: Based on record review, the Licensee did not report the construction to the licensing agency. This posed a potential safety risk to three of three residents in care.

Maintain facilities for fire and panic safety

Based on LPA observation, the licensee did not comply with the section cited above when the sole fire extinguisher was found to be inoperable, which poses an immediate safety risk to persons in care.