Westborough Manor 6

Based on staff records reviewed, 5/5 staff were observed to not have the required training which poses an immediate health, safety or personal rights risk to persons in care.

Based on record reviewed, facility did not have any documentation of the emergency drills being conducted quarterly which poses an immediate health, safety or personal rights risk to persons in care.

Update reappraisal at required intervals

Based on resident records reviewed, the licensee did not comply with the section cited above as 5/5 residents did not have documentation of resident reappraisals which poses/posed a potential health, safety or personal rights risk to persons in care.

Onsite food stock levels for nonperishables and perishables

Based on observation, LPA did not observe 7 day non-perishables which poses/posed a potential health, safety or personal rights risk to persons in care.

Ensure hazardous items are locked and not unattended

Based on observations, LPA observed sharps to be unlocked and accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.

Conformance with applicable laws and regulations

87405 Administrator - Qualifications and Duties..(d) The administrator shall have the qualifications..(2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirment is not met as evidenced by based on observation, record review and interview, the administrator did not ensure the facility has an active General Liability Insurance Policy which poses an immediate health and safety risks to residents in care.

Prohibit false or misleading facility statements

87207 False Claims ..No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement is not met as evicenced by based on interviews, observation and record review, the administrator/licensee provided an insurance policy that was terminated in 2018-2019 and when it was active, it did not insure this facility which poses an immediate health risks to residents in care.

1569.605Liability insurance; coverage requirements...Based on interview, observation and record reveiw, This requirement is not met as evidenced by the facility did not provide a copy of the current liability insurance after several verbal and written reminders which poses a potential risk to residents in care.

Maintain physician order documentation in resident record

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 4 out of 6 residents have bedrails by the head of the bed without a physician's order which poses an immediate health, safety or personal rights risk to persons in care.

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above 5 out of 6 residents did not a reappraisal which poses/posed a potential health, safety or personal rights risk to persons in care.

Living accommodations aligned with facility function

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above LPA observed staff living/rest area in the garage as which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 3 out of 3 staff did not have a current CPR and first aid training which poses an immediate health, safety or personal rights risk to persons in care.

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above 3 out of 3 staff did not have any training from 2023 to present which poses an immediate health, safety or personal rights risk to persons in care.

Report serious outbreaks and major accidents

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 4 out 6 residents tested positive for COVID-19 and the facility did not reported to CCL and LPH which poses an immediate health, safety or personal rights risk to persons in care.

Perform a pre-admission resident appraisal

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 4 out of 6 resident did not have a copy of the pre-admission appraisal which poses an immediate health, safety or personal rights risk to persons in care.

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the facility did not have any documentation of the emergency drills which poses an immediate health, safety or personal rights risk to persons in care.

87405 Administrator - Qualifications and Duties..(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply..(1) Knowledge of the requirements for providing care and supervision.. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by the administrator failed to ensure residents are adequately fed and bills are paid in a timely manner which poses an immediately health risk to residents in care.

Financial plan and required reporting obligations

87213 Finances..The licensee shall have a financial plan that conforms to the requirements of Section 87155, Application for License, and that assures sufficient resources to meet operating costs for care of residents; This requirement is not met as evidenced by based on the audit result, licensee is not making sufficient income to meet operating expenses which poses an immediately health risk to residents in care.

Diet quality and preparation in safe healthful manner

87555 General Food Service Requirements..a)The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council.. This requirement is not met as evidenced by based on the audit result, the facility failed to supplied food to resident to meet the nutritional guidelines which poses an immediately health risk to residents in care.

87205 Accountability of Licensee Governing Body..a) The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility..(b) If the licensee is a corporation or an association, the governing body shall be active, and functioning in order to assure accountability.. This requirement is not met as evidenced by based on the audit result, the licensee failed to pay rent, utility bills on time and licensee's corporation status with Secretary of State is Franchise Tas Board (FTB) suspended which poses an immediately risk for residents in care.

Ensure hazardous items are locked and not unattended

Based on observation and interview, the licensee did not comply with the section cited above- during the facility tour that was provided by the administrator, LPA observed chemical and toxins are stored in a closet, however, door was not locked as there was a blue tape covering the lock that prevented the door from locking which poses an immediate health, safety or personal rights risk to persons in care.

Safe, healthful, comfortable accommodations

Based on observation and interview the licensee did not comply with the section cited above in as LPA did not observe any COVID-19/Infection control postings by the front entrance and in the facility which poses/posed a potential health, safety or personal rights risk to persons in care.