Routine inspection·December 10, 2023

Citations

9 citations recorded^*CCLD

• 1569.618(c)(3)Type A

  (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Based on: LPA did not observe current first aid/CPR certificates for staff during this visit. This violation poses an immediate health, and safety risk to residents in care.

• 87303(c)Type B

  Keep window screens clean and in repair

  Maintenance and OperationAll window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by: Based on: LPA observed screen at front of facility window to be not in good repair. This violation poses a potential health, and safety risk to residents in care.

• 87406(g)Type A

  Administrator Certification RequirementsCertificates issued under this section shall be renewed every two (2) years provided the certificate holder has complied with all renewal requirements. This requirement is not met as evidenced by: Based on: LPA did not observe an Administrator certificate for Jose Nevarez nor supporting documents with proof of payment for renewal. This violation poses an immediate health, and safety risk to residents in care.

• 87411(f)Type A

  Health screening and fitness requirements

  Personnel Requirements - GeneralAll personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by: Based on:LPA did not observe TB results for staff during this visit. This violation poses an immediate health, and safety risk to residents in care.

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• 87465(8)(AType A

  Incidental Medical and Dental CareIf a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following:A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency. Sterile first aid dressings. Bandages or roller bandages. Scissors. Tweezers. Thermometers. This requirement is not met as evidenced by: Based on: LPA did not observe a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, tweezers, and antiseptic solution. This violation poses an immediate health, and safety risk to residents in care.

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• 87465(h)(2)Type A

  Store centrally held medications in locked secure place

  Incidental Medical and Dental CareThe following requirements shall apply to medications which are centrally stored: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: LPA observed medications belonging to staff accessible and on top of refrigerator not locked.This violation poses an immediate health, and safety risk to residents in care.

• 87470(c)Type A

  Infection control plan required in operations plan

  Infection Control RequirementsAn Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. This requirement is not met as evidenced by: Based on: LPA inquired with both staff regarding the Infection Control Plan. LPA did not receive an answer from either.This violation poses an immediate health, and safety risk to residents in care.

• 87506(a)Type B

  Maintain separate complete record for each resident

  Resident RecordsThe 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 is not met as evidenced by: Based on: LPA observed records of residents incomplete, without signatures and dates. This violation poses a potential health, and safety risk to residents in care.

• 87405(a)Type A

  Certified administrator requirements and substitute coverage

  Administrator - Qualifications and DutiesAll facilities shall have a qualified and currently certified administrator...When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section... This requirement is not met as evidenced by: Based on: LPA did not observed an LIC308 Designation of Responsibility as designee on file was sleeping during this visit. This violation poses an immediate health, and safety risk to residents in care.