Tlc Home Care Ii

Based on record review, the licensee did not have documentation of the required hours of dementia care training for staff who assist residents with personal activities of daily living, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee does not have an evacuation chair at each stairwell, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on interview of Administrator, the licensee did not comply with the section cited above in 1 out of 1 Fire Safety Plans which the Administrator could not produce, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on interview of Administrator, the licensee did not comply with the section cited above in 1 out of 1 facility sketches which did not show evacuation procedures, which poses/posed a potential health, safety or personal rights risk to persons in care.

ADMINISTRATOR--QUALIFICATIONS/ DUTIESThe administrator shall have the responsibility to administer the facility in accordance with these regulations and established policy, program, and budget.This requirement is not met, as administrator failed to adhere to local ordinances on building construction, fire safety, and licensing requirements when facility retained bedridden residents. This posed an immediate health, safety, or personal rights risk to residents in care. Furthermore, in interviews with the administrator, they acknowledged a lack of knowledge regarding their infection control plan and practices.

Care of Bedridden Residents: To accept or retain a bedridden person, a facility shall ensure the following: The facility's plan of operations shall include a statement of how the facility intends to meet the overall health, safety and care needs of bedridden persons. Based on observation and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to residents. The facility currently has 2 bedridden residents in their care.

Licensee must supervise facility operations

Accountability of Licensee Governing Body: The licensee... shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves. This requirement was not met , as licensee failed to operate facility in conformance with regulations, which poses an immediate health, safety, or personal rights risk to clients in care.

Facility must clear fire safety for bedridden persons

Fire Safety: 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. This requirement is not met, as there is a bedridden client in room 2 upstairs and 5 downstairs. Licensee failed to comply with conditions and limitations of fire clearance approved for 9 non-ambulatory clients, and no bedridden, which poses an immediate health, safety, and personal rights risk to clients in care.

POSTURAL SUPPORTSPostural supports shall be fastened or tied in a manner that permits quick release by the resident.This requirement is not met, as client in room 5 is observed seated in wheelchair in living room, with beige gait belt around her waist and wheelchair, with buckle in back. Licensee failed to ensure that postural support is fastened in front, so client can easily unfasten it. This poses an immediate health, safety, or personal rights risk to clients in care.

POSTURAL SUPPORTSBed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met, as client in room 5 on ground level uses full bed rail. Client is not receiving hospice services. Licensee failed to ensure that full bed rails are only used for hospice residents, which poses an immedialte health, safety or personal rights risk to clients in care.

PERSONAL ACCOMMODATIONS/SVCSNo bedroom of a resident shall be used as a passageway to another room, bath or toilet.This requirement is not met, as administrator "office" is accessed from room #4 on upper level. This "office" appears to be a large closet. Licensee failed to ensure that bedrooms are not passageways to another room, which poses a potential health, safety or personal rights risk to clients in care.

Document behavioral expression and related causes

Appraisals (c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months. This requirement is not met as evidence by record reviews of R1, R2, and R3. R1’s needs and services plan (LIC625) was dated 01/05/2022 and unsigned. R2 and R3 does not have a copy of the needs and services plan.

Store disinfectants separately from food supplies

Storage Space: (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.This requirement is not evidenced by interview with administrator and observation of chemicals on the floor and accessible to persons in care. This poses an immediate health and safety risk to persons in care.

Requirement for building permit before construction

This is an Amended ReportThe report was generated in error This is an Amended ReportThe report was generated in error

Maintain physician order documentation in resident record

Postural Supports (a) Based on the individual's preadmission appraisal, Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support. This requirement is not met as evidence by: R2 has half bed rails up by the head of the bed and there was no written order from their physician which poses a potential health risks to residents in care.

Food quality controls and rejected damaged goods

General Food Service Requirements: All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by interview of administrator and observation of a slice of Carrot cake on a table and multiple expired food/food products inside of refrigerators upstairs and downstairs.

Maintain facility in clean, safe, sanitary condition

Maintenance and Operation: (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by an interview with the administrator and observation of bedroom 3 which has a wall that needs to be patched and/or painted.

Rapid-growth perishable foods must be covered

General Food Service Requirements:All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures.This requirement is not met as evidenced by observation of food that needs to be refrigerated after opening not refrigerated.

Store centrally held medications in locked secure place

Incident Medication and Dental Care: 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 observation of staff and resident medication in areas throughout facility that are accessible to persons in care which poses an immediate health and safety risk to residents.