Routine inspection·November 3, 2023

Citations

14 citations recorded^*CCLD

• 87633(b)Type B

  Facility must keep complete hospice care plan on file

  Based on record review, facility does not have a hospice plan of operation/ care plan for residents who are receiving hospice services.

• 1569.625(c)Type B

  Based on record review, administrator was unable to provide LPA with staff training documentation; dementia care, safe food handling, emergency disaster drills, etc.

• 1569.695(e)Type B

  Based on record review, facility did not have the following information readily available; resident roster with resident date of birth, resident's medication list, resident's emergency contact sheet, and resident needs and service plan (for each resident)

• 87208(a)(12)Type B

  Based on record review and interviews, Administrator acknowledged the facility did not have an infection control plan which poses a potential health and safety risk for residents in care.

• 87303(e)(2)Type B

  Provide resident hot water for personal care

  Based on observations, water temperature throughout the facility measured between 85.1 degrees F to 95.7 degrees F.

• 87307(d)(6)Type B

  Passageways and stairways kept clear

  Based on obserations, LPA observed furniture on the outdoor passageway which can cause tripping hazards and fire safety hazards.

• 87309(a)Type A

  Ensure hazardous items are locked and not unattended

  Based on observations, cabinet with chemicals and toxins were unlocked and accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.

• 87457(c)Type B

  Complete admission suitability appraisal

  Based on record review; 4/4 resident records observed did not have an indiviudualized needs and service plan.

• 87555(b)(8)Type A

  Food quality controls and rejected damaged goods

  Based on observations, LPA observed an expired gallon of milk in the fridge. In addition, LPA observed open bottles of mayonnaise and mustard in the kitchen pantry.

• 87632(d)(2)Type B

  Notification to department after hospice care starts

  Based on record review, facility failed to notify Licensing within five days of the initiation of hospice care for Resident 1 (R1).

• 87705(b)Type B

  Based on record review, facility did not have a plan of operation for residents with dementia.

• 87705(c)(5)Type B

  Based on record review 4/4 residents did not have an updated physician's report done within the last year. 3/4 resident records observed, were residents who have a diagnosis of dementia.

• 87705(f)(1)Type A

  Notify agency before locking doors or gates

  Based on observations, LPA observed sharps unlocked and ccessible to residents which poses an immediate health, safety or personal rights risk to persons in care.

• 87705(j)Type A

  Based on observation, door alarms on resident doors; from resident rooms to outdoor passageways were observed to be off which poses an immediate health, safety or personal rights risk to persons in care.