Routine inspection·January 2, 2024

Citations

9 citations recorded^*CCLD

• 87507(a)Type B

  Must complete individual written admission agreements

  Based on client record reviews, the licensee did not comply with the section cited above, as admission agreements for all clients are missing or incomplete, which poses a potential health, safety or personal rights risk to persons in care.

• 1569.69(b)Type B

  Based on staff record review, the licensee did not comply with the section cited above, as medication staff #4 has not received annual medication training since 2/2022, which poses a potential health, safety or personal rights risk to persons in care.

• 87202(a)(2)Type A

  Facility must clear fire safety for bedridden persons

  Based on client record review, the licensee did not comply with the section cited above, as two out of 6 residents are deemed to be BEDRIDDEN, per MD reports, but facility is not approved for bedridden residents and does not maintain fire clearance for bedridden clients.This poses an immediate health, safety or personal rights risk to persons in care.

• 87355(e)(3)Type A

  Request a transfer of criminal record clearance

  Based on staff record review, the licensee did not comply with the section cited above, as night staff #2 does not have criminal record clearance associated to this facility. 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 record review, the licensee did not comply with the section cited above, as staff #2, #3, #6 do not have proof of current first-aid training, which poses a potential health, safety or personal rights risk to persons in care.

• 87411(f)Type B

  Health screening and fitness requirements

  Based on staff record review, the licensee did not comply with the section cited above, as health screening and/or TB test results are not maintained for staff 2, #4, #6, which poses a potential health, safety or personal rights risk to persons in care.

• 87465(h)(5)Type B

  Keep prescriptions in original containers

  Based on observation, the licensee did not comply with the section cited above, as clients' medications are pre-poured 10 days in advance. Seven-day pill organizers are observed, as well as plastic baskets containing small plastic cups for each clients' AM, PM, BT medications for 3 additional days. This practice poses a potential health, safety or personal rights risk to persons in care.

• 87608(a)93)Type B

  Based on client record review, the licensee did not comply with the section cited above, as ALL residents have bed rails--hospice client #4 has FULL bed rails. There are no MD orders for half bed rails and hospice care plan for client #4 does not include full bed rails.This poses a potential health, safety or personal rights risk to persons in care.

• 1569.625(b)(2)Type B

  Based on review of staff training, the licensee did not comply with the section cited above, as there is no evidence of required 20 hours of staff training for staff 1, 2, 3, 4, 6, including 8 hours of dementia training and 4 hours specific to postural supports, restricted health conditions and hospice care. This poses a potential health, safety or personal rights risk to persons in care.