Routine inspection·January 14, 2025

Citations

9 citations recorded^*CCLD

• 1569.185(e)Type A

  HEALTH AND SAFETY CODEThe failure of an applicant for licensure or a licensee to pay all applicable and accrued fees and civil penalties shall constitute grounds for denial or forfeiture of a license.This requirement is not met, as licensee has failed to pay annual licensing renewal fees for 2023, 2024 and 2025, which poses an immediate health, safety or personal rights risk to clients in care.Licensee was reminded to pay licensing fee on 1/30/24 during annual visit.

• 1569.69(b)Type B

  HEALTH AND SAFETY CODEEach employee who received training and passed the exam required in paragraph (5) of subdivision (a)... who continues to assist with the self-administration of medicines, shall also complete 4 hours of in-service training on medication-related issues in each succeeding 12-month period. This requirement is not met, as all staff have not received 4 hours of continuing medication training, which poses a potential health, safety or personal rights risk to clients in care.

• 1569.696Type B

  HEALTH AND SAFETY CODEAll RCFEs shall provide training to direct care staff on postural supports, restricted conditions or health services, & hospice care as a component of the training requirements specified in Section 1569.625. The training shall include...4 hours of training thereafter of in-service training per year on the subject of serving those residents. This requirement was not met, as staff #3 and #4 have not received this training for 2024. Licensee failed to ensure that all staff receive required training, which poses a potential health, safety or personal rights risk to clients in care.

• 87303(a)Type B

  Maintain facility in clean, safe, sanitary condition

  MAINTENANCE AND OPERATIONThe 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 discarded furnishings are observed in backyard--table, chairs, bed frame, 2 bicycles, scooters, shelf--and pipe and insulation are exposed in room #6 as a 3' x 18" section of ceiling is missing. This poses a potential health, safety or personal rights risk to clients in care.

• 87309(a)Type A

  Ensure hazardous items are locked and not unattended

  STORAGE SPACE AND ACCESSThe licensee shall ensure that disinfectants, cleaning solutions, poisonous substances... and other similar items which could pose a danger to residents are in locked storage and are not left unattended...This requirement is not met, as Windex is stored in common bathroom cabinet, accessible to clients. Licensee failed to ensure that cleaning solutions are secured, which poses an immediate health, safety or personal rights risk to clients in care.

• 87457(c)Type B

  Complete admission suitability appraisal

  PREADMISSION APPRAISALPrior to admission a determination of the prospective resident's suitability for admission shall be completed & shall include an appraisal of their individual service needs...This requirment is not met, as appraisals for clients #2, #3, #4, #5 are missing or incomplete. Licensee failed to ensure that all residents have completed, signed and dated appraisals on file, which poses a potential health, safety or personal rights risk to clients in care.

• 87465(h)(2)Type A

  Store centrally held medications in locked secure place

  INCIDENTAL MEDICAL CARECentrally 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 was not met, as 2 bottles of Vit D3 stored in common bathroom,and acetaminophen and Vit C stored in kitchen cabinet, where items are accessible to residents. Licensee failed to ensure that medications are stored where inaccessible to clients, which poses an immediate health, safety or personal rights risk to clients in care.

• 87468.1(a)(13)Type B

  PERSONAL RIGHTSResidents in all RCFEs shall have the personal right to have access to individual storage space for private use.This requirement is not met, as personal items belonging to staff are stored in closet in client room #3. Licensee failed to ensure that residents' closets are limited to residents' personal items, and not used by staff. This poses a potential health, safety or personal rights risk to clients in care.

• 87633(b)Type B

  Facility must keep complete hospice care plan on file

  HOSPICE CARE OF TERMINALLY ILLA current and complete hospice care plan shall be maintained in the facility for each hospice resident and include specific information. This requirement is not met, as there is no hospice care plan maintained for client #3, including use of half bed rails. Licensee failed to ensure that hospice care plan is maintained for all hospice clients, which poses a potential health, safety or personal rights risk to clients in care.