Family Affair Care Home

Provide resident hot water for personal care

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the hot water temperature in the bathrooms was measured at 91- 151 degrees F 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 LPA did not observe any "No Smoking- Oxygen in Use" signs at the facility 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 administrator was not able to provide proof that emergency drills were conducted accordingly which poses an immediate health, safety or personal rights risk to persons in care.

Encourage resident participation in varied planned activities

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as during the annual visit on 3/18/2025 and the continuation visit on 3/26/2025, LPA did not observe any activities were provided to the residents. LPA observed majority of the residents were watching TV and others were in bed which poses/posed a potential health, safety or personal rights risk to persons 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 LPA observed 10 out of 10 residents with bed rails with a written order from a physician 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 LPA observed R1 and R7 have oxygen and the administrator did not make a report to the local fire jurisdiction 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 the administrator was not able to provide training records for S1 and S2 to ensure they are knowledgeable and has the ability to operate oxygen equipment which poses/posed a potential health, safety or personal rights risk to persons in care.

Maintain facility in clean, safe, sanitary condition

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed garage was cluttered, uncleaned cat food all over the ground, files, dirty plastic bags on the floor, table, unknown brown liquid bottle on the table, lighter, cigarettes on top of the laundry, and soiled linens on the floor which poses an immediate health, safety or personal rights risk to persons in care.

Maintain fire clearance before retaining specified persons

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the facility converted a private room (bedroom 3) into a 2 bedroom without a fire clearance was 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 S3 and S4 did not have any documents in their files to verify this information which poses an immediate health, safety or personal rights risk to persons in care.

Include required health screening documents

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 4 out of 4 staff did not have proof that their health screen was completed which poses an immediate health, safety or personal rights risk to persons in care.

Maintain required personnel records for staff

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as S1 and S2 have missing documents from the personnel records and S3 and S4 did not have a personnel file which poses an immediate health, safety or personal rights risk to persons in care.

Request transfer of criminal record exemption

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as S3 and S4 did not have proof that background/fingerprint clearance process were completed which poses an immediate health, safety or personal rights risk to persons in care.

Maintain required personnel records for staff

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 1 out 4 staff files was not maintained at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.

Request transfer of criminal record exemption

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 2 out of 3 staff were not associated with the facility which poses an immediate health, safety or personal rights risk to persons in care.

Maintain records of centrally stored medication dosages

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 3 out of 4 residents did not have a centrally stored medication in their file which poses/posed a potential health, safety or personal rights risk to persons in care.

Document required staff training and orientation

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 1 out of 4 staff did not have any proof that training and orientation were completed upon hire which poses an immediate health, safety or personal rights risk to persons in care.

Update reappraisal at required intervals

87463 Reappraisals: (a) ...The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to...Violation of this regulation is not met as evidenced by: Based on interviews conducted and information collection, the facility administrator acknowledged that she refused to take R1 back to the community because the hospital did not properly assess her, however instead of administrator going to assess her, the administrator called R1's responsible party to assess R1 prior to discharge. In addition, the administrator acknowledged she did not reassess R1 when R1 was in the hospital or when R1 returned back to the community.

Report specified resident events within seven days

87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below...Violation of this regulation is evidenced by: Based on the interviews conducted an information collected, the facility failed to submit an incident report for an incident that occurred on 2/15/23. In addition the facility adminsitrator acknowledged that she was unaware that a report had to be submitted to CCL.

POSTURAL SUPPORTSBed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.This violation exists based on observation of full bed rails on bed of client #4 in shared room beyond living room. Client is not on hospice care. Licensee failed to ensure that full bed rails are NOT used, which poses an immediate health, safety or personal rights risk for clients in care.

Safe, healthful, comfortable accommodations

PERSONAL RIGHTSResidents in all RCFEs shall have the following personal right:To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This requirement is not met, as there is no COVID screening or temperature check upon arrival at facility for visitors. Visitor log does not include date, contact information, confirmation that COVID symptoms are absent, and temp check. Licensee failed to ensure that visitors are properly COVID screened, which poses a potential health, safety or personal rights risk to clients in care.

Assist residents with self-administered medication

87465 Incidental Medical and Dental Care...(a)A plan for incidental medical... shall be developed by each facility..(4) The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidenced by: the facility failed to assist R1's pain medication during the night upon R1's request as prescribed by R1's physician posed an immediate health and safety risks to resident in care.

Prohibition on using other rooms as bedrooms

87307 Personal Accommodations and Services..(a)Living accommodations...The facility shall be large enough to provide comfortable living accommodations and privacy for the residents...(2)Resident bedrooms shall be provided which meet..(B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This requirement was not met as evidenced by: the facility moved 2 male residents who were sharing a room into the living room to accommodate a female resident who did not get along with her roommate which posed an immediate health and safety risks to resident in care.

87629 Injections..(a) The licensee shall be permitted to accept or retain a resident who requires intramuscular,..intradermal injections if the injections are administered by the resident or by an appropriately skilled professional. This requirement is not met as evidenced by: R2 was not able to administer injections and injections were administered by S1 who was not an appropriately skilled professional which posed an immediate health and safety risks to residents in care.

Safe, healthful, comfortable accommodations

87468.1 Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful... This requirement is not met as evidenced by: during the 10-day initial complaint visit, LPA observed staff #1 was not wearing any face covering which posed an immediate health and safety risks to resident in care.

Complete admission suitability appraisal

87457 Pre-Admission Appraisal - General..(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal ... This requirement is not met as evidenced by: the facility did not conduct a pre-admission appraisal of R1 which resulted the facility not able to meet R1's blood sugar management needs which posed an immediate health and safety risks to residents in care.

Regular observation and documentation of resident changes

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical,...When changes such as...physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: the facility failed to observe R1's blood sugar level which posed an immediate health and safety risks to resident in care.