Routine inspection·November 5, 2024

Citations

19 citations recorded^*CCLD

• 1569.625(b)(2)Type B

  Based on staff records review, the licensee did not comply with the section cited above in 2 out of 5 records reviewed, which poses a potential health, safety or personal rights risk to persons in care.- There is no documentation that Staff #5 and #6 have received 4 hours of training on postural supports, restricted health conditions and hospice care, and 8 hours of dementia care training.

• 1569.695(c)Type B

  Based on absence of documentation and confirmation by staff, the licensee did not comply with the section cited above, as there is no documentation of disaster drills available for review. This poses a potential health, safety or personal rights risk to persons in care.

• 1569.695(e)Type B

  Based on client records review, the licensee did not comply with the section cited above, as there is no documentation available to staff for 3 residents, in the event of an emergency. This poses a potential health, safety or personal rights risk to persons in care.

• 87303(a)Type B

  Maintain facility in clean, safe, sanitary condition

  Based on observation, the licensee did not comply with the section cited above, as backyard is strewn with items: metal shelving, suitcase, 7 large plastic storage boxes with lids, electric fireplace mantle, plastic sheeting, boxes of toys, 5-gallon water containers, bicycles, exercise equipment, plastic garbage containers. Backyard fence is missing several boards. This poses a potential health, safety or personal rights risk to persons in care.

• 87303(e)(2)Type A

  Provide resident hot water for personal care

  Based on observation, the licensee did not comply with the section cited above, as hot water temperature tested at 133 degrees in client bathroom. This poses an immediate health, safety or personal rights risk to persons in care.

• 87307(d)(6)Type B

  Passageways and stairways kept clear

  Based on observation, the licensee did not comply with the section cited above, as side yard on east side is not easily accessible because barbecue grill, compressor tank, exercise bicycle and cabinet partially obstruct passageway to gate.This poses a potential health, safety or personal rights risk to persons in care.

• 87309(a)Type A

  Ensure hazardous items are locked and not unattended

  Based on observation, the licensee did not comply with the section cited above, as Lysol, Zep liquid cleaner and Bona floor cleaner are stored in unlocked cabinet in common bathroom and two containers of Zerex anti-freeze auto coolant, paint can, and multiple containers of cleaning products are observed on backyard patio.This poses an immediate health, safety or personal rights risk to persons in care.

• 87411(c)(1)Type B

  First aid training requirements

  Based on staff records review, the licensee did not comply with the section cited above in 2 out of 5 records reviewed, which poses a potential health, safety or personal rights risk to persons in care.- There is no evidence that Staff #5 and #6 have current first aid training.

• 87412(a)(11)Type B

  Include required health screening documents

  Based on staff records review, the licensee did not comply with the section cited above in 2 out of 5 records reviewed, as health screening and/or TB test results are not maintained for Staff #3 and #4 which poses a potential health, safety or personal rights risk to persons in care.

• 87412(d)Type A

  Keep administrator certification or recertification records

  Based on absence of current administrator certificates and confirmation from staff, the licensee did not comply with the section cited above, as there is no one currently who maintains a current RCFE administrator certificate. RCFE administrator certificates for Staff #1 and #2 expired in 2018 This poses an immediate health, safety or personal rights risk to persons in care.

• 87457(c)Type B

  Complete admission suitability appraisal

  Based on client records review, the licensee did not comply with the section cited above in 3 out of 5 records reviewed, which poses a potential health, safety or personal rights risk to persons in care.- There are no appraisals on file for clients #3, #4, #5.

• 87458(a)Type B

  Obtain baseline medical assessment before resident admission

  Based on client records review, the licensee did not comply with the section cited above in 3 out of 5 records reviewed, which poses a potential health, safety or personal rights risk to persons in care.- There are no MD assessments maintained for clients #3, #4, #5.

• 87506(a)Type A

  Maintain separate complete record for each resident

  Based on client records review, the licensee did not comply with the section cited above in 3 out of 5 client records reviewed, which poses an immediate health, safety or personal rights risk to persons in care.- There are no client records maintained for clients #3, #4, #5.

• 87507(a)Type B

  Must complete individual written admission agreements

  Based on client records review, the licensee did not comply with the section cited above in 4 out of 5 records reviewed, which poses a potential health, safety or personal rights risk to persons in care.- There are no admission agreements maintained for clients #3, #4, #5, and admission agreement for client #1 is not signed.

• 87508(a)Type B

  Based on client records review, the licensee did not comply with the section cited above, as roster of current residents is not maintained. This poses a potential health, safety or personal rights risk to persons in care.

• 87608(a)(3)Type B

  Maintain physician order documentation in resident record

  Based on clients records review, the licensee did not comply with the section cited above in 5 out of 5 records reviewed, which poses a potential health, safety or personal rights risk to persons in care.- All residents have half bed rails on their beds, and there are no MD orders on file

• 87618(b)(3)(B)Type B

  Based on observation, the licensee did not comply with the section cited above, as there are no oxygen in use signs posted at entrance doors or bedroom doors for 3 residents who have oxygen in their rooms. This poses a potential health, safety or personal rights risk to persons in care.

• 87633(b)Type B

  Facility must keep complete hospice care plan on file

  Based on client records review, the licensee did not comply with the section cited above, as client #5 is receiving hospice care, but there is no hospice care plan maintained. This poses a potential health, safety or personal rights risk to persons in care.

• 87465(h)Type A

  Apply centrally stored medication safeguards

  Based on absence of Centrally Stored Medications Records, the licensee did not comply with the section cited above , as record of centrally stored medications is not maintained. This poses an immediate health, safety or personal rights risk to persons in care.