Incident investigation·February 15, 2023

Citations

5 citations recorded^*CCLD

• 87211(a)(1)Type B

  Report specified resident events within seven days

  87211(a)(1) Reporting Requirements: 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… Based on records review, the licensee did not comply with the section cited above when staff did not submit a Serious Illness/Serious Injury report for R2’s change of condition within seven days of the occurrence which poses a potential health and safety risk to residents in care.

• 87632(d)(2)Type B

  Notification to department after hospice care starts

  87632(d)(2) Hospice Waiver: The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. Based on records review, the licensee did not comply with the section cited above when staff did not notify R1’s hospice placement within five working days from date of placement which poses a potential health and safety risk to residents in care.

• 87705(f)(2)Type A

  Fire approval and staff access to unlock systems

  Care of Persons with Dementia (f)The following shall be stored inaccessible to residents with dementia: (2)Over-the-counter medication,..., and toxic substances ...,cleaning supplies and disinfectants. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the above section by failing to remove and secure R1’s antifreeze, thus allowing R1 to ingest the antifreeze causing death, which posed an immediate health and safety risk to residents in care.

• 87303(a)Type B

  Maintain facility in clean, safe, sanitary condition

  87303(a) Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of Residents, employees and visitors.This requirement is not met as evidenced by: Based on interviews conducted, the licensee did not comply with the section cited above by Elevator 1 and Elevator 2 were not in working condition on 1/18/2023 and 2/10/2023; Elevator #2 was not working on 2/11/2023, 2/13/2023, and 2/14/2023. This posed a potential health and safety risk to residents in care.

• 87465(c)(2)Type A

  Give PRN medication by physician order

  87465(c)(2) Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions.This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above when staff did not follow physician’s orders for medications, which posed an immediate health and safety risk to residents in care.