Routine inspection·June 18, 2024

Citations

10 citations recorded^*CCLD

• 87463(a)Type B

  Update reappraisal at required intervals

  Based on clients record review, the licensee did not comply with the section cited above in 2 out of 6 files reviewed. Appraisal for client #2 is dated 10/2017 and must be updated No appraisal for client #3. This poses a potential health, safety or personal rights risk to persons in care.

• 1569.625(b)(2)Type B

  Based on confirmation from administrator and absence of documentation, the licensee did not comply with the section cited above, as there is no evidence that staff have received required annual training, including dementia, postural supports, restricted health conditions, hospice care. This poses a potential health, safety or personal rights risk to persons in care.

• 1569.695(b)Type B

  Based on confirmation from administrator and absence of training records, the licensee did not comply with the section cited above, as all staff have not received ongoing training on responding to emergencies and disasters. 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 discarded commodes, furniture, wheelchair, mattresses are stored in backyard, which poses a potential health, safety or personal rights risk to persons in care.

• 87458(b)(1)Type B

  Based on review of client records, the licensee did not comply with the section cited above, as MD report for client #2 does not include diagnoses, which poses a potential health, safety or personal rights risk to persons in care.

• 87465(h)(6)Type B

  Record centrally stored prescriptions and refill data

  Based on review medications and Centrally Stored Medications Records for clients #3 and #5, the licensee did not comply with the section cited above, as dates are inaccurate and incomplete, strength is not legible, Rx numbers are not recorded, some Rx medications are not recorded on CSMRs. This poses a potential health, safety or personal rights risk to persons in care.

• 87470(c)Type B

  Infection control plan required in operations plan

  Based on record review and confirmation from administrator, the licensee did not comply with the section cited above, as an Infection Control Plan has not been developed. This poses a potential health, safety or personal rights risk to persons in care.

• 87705(c)(5)Type B

  Based on client record review, the licensee did not comply with the section cited above, as client #1 is diagnosed with dementia, but MD report and appraisal are 5 years old. This poses a potential health, safety or personal rights risk to persons in care.

• 1569.267(d)Type B

  Based on confirmation from administrator and absence of training documentation, the licensee did not comply with the section cited above, as there is no evidence that any staff have received annual training on residents' personal rights, which poses a potential health, safety or personal rights risk to persons in care.

• 1569.695(c)Type B

  Based on confirmation from administrator and absence of documentation, the licensee did not comply with the section cited above, as there is no documentation that disaster or emergency drills have been conducted quarterly.This poses a potential health, safety or personal rights risk to persons in care.