Routine inspection (multi-day)·January 16, 2025

Citations

5 citations recorded^*CCLD

• 1569.626(a)(2)Type B

  HEALTH AND SAFETY CODEAll RCFEs shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: 8 hours of in-service training per year on the subject of serving residents with dementia. This requirement was not met, as there is no record that staff #3 and #4 received ANY training in 2024. Licensee failed to ensure that staff received required training, which poses a potential health, safety or personal rights risk to clients in care.

• 1569.69(b)Type B

  HEALTH AND SAFETY CODEEach employee who received training, passed the examination required in paragraph (5) of subdivision (a), who continues to assist with the self-administration of medicines, shall also complete 8 hours of training on med -related issues in each succeeding 12- month period. This requirement was not met, as S1 & S ____ who manage and administer clients' medications, have not received annual medication training for 2024. Licensee failed to ensure that staff who handle medications receive required training, which poses a potential health, safety or personal rights risk. S1 received 1 hour of med training in 2024 & there is no record that S __ received any medication training in 2024.

• 1569.695(f)(2)Type B

  HEALTH AND SAFETY CODEA facility shall have a set of keys available to facility staff on each shift for use during an evacuation that provides access to all occupied resident units, facility vehicles, all exit doors, all cabinets...or files that contain elements of the emergency disaster plan, including... food supplies & protective shelter supplies. This requirement was not met, as extra set of keys is not maintained in the event of an emergency. Licensee failed to maintain spare set of keys, which poses a potential health, safety or personal rights risk. This was discussed w/ administrator on 1/30/24.

• 87465(h)(6)Type B

  Record centrally stored prescriptions and refill data

  iNCIDENTAL MEDICAL CAREA record of centrally stored prescription medications for each resident shall be maintained and include names of the resident for whom prescribed, prescribing physician and pharmacist, drug name, strength and quantity, dates filled, started & expiration, prescription number and instructions.This requirement is not met, as 2 OTC meds for client #2, OTC Senna and Rx Vit D3 for C5, & medications received but not yet started, are not recorded on CSMR. This poses a potential health, safety or personal rights risk to clients in care.

• 87609(b)(4)(B)Type B

  ALLOWABLE HEALTH CONDITIONS/ USE OF HOME HEALTH AGENCIES..Written agreement shall include day and evening contact information for the HH agency...method of communication between the agency & facility, which may include verbal contact, electronic mail, or logbook. This requirement was not met, as there are no progress notes maintained from home health providers whenever they visit a resident. Licensee failed to ensure maintenance of HH notes from visiting providers, which poses a potential health, safety or personal rights risk. This was discussed with administrator on 1/30/24.