Complaint·September 24, 2024

Citations

9 citations recorded^*CCLD

• 87303(a)Type B

  Maintain facility in clean, safe, sanitary condition

  87303 Maintenance and Operation(a) 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 of observation, two air vents above the stove and in the hallway were not covered and filled with dust which poses a potential health, safety or personal rights risk to persons in care.

• 87303(c)Type B

  Keep window screens clean and in repair

  87303 Maintenance and Operation (c) All window screens shall be clean and maintained in good repair.This requirement was not met as evidenced by: Based on observation, two window screens in resident's room and 1 door screen for exit door was not clean and not in good repair which poses a potential health, safety or personal rights risk to persons in care.

• 87307(d)(6)Type A

  Passageways and stairways kept clear

  87307(d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.This requirement is not met as evidenced by: Based on observation and interview, the licensee did not ensure that sliding exit doors tracks were free of obstruction. LPAs observed a pole obstructing the sliding exit door tracks which poses an immediate health, safety or personal rights risk to persons in care.

• 87457(c)Type B

  Complete admission suitability appraisal

  87457(c)Prior to admission ... shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria.This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above when 1 out of 2 resident files did not create an Appraisal/ Needs and Services plan which poses a potential health, safety or personal rights risk to persons in care.

• 87463(b)Type B

  Document required significant condition changes

  87463 (b) The licensee shall immediately bring any such changes to the attention of the resident's physician and his family or responsible person.This requirement is not met as evidenced by: Based on interview and record review, R2's Appraisal/Needs and Services Plan was not signed by R2 and/or R2's responsible party which poses a potential health, safety or personal rights risk to persons in care.

• 87465(h)(2)Type A

  Store centrally held medications in locked secure place

  87465 (h)(2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.This requirement was not met as evidenced by: Based on observation, 1 prescription medication was in the refrigerator unlocked and a drawer in the kitchen which contains resident's medication was unlocked and accessible to residents which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.

• 87465(h)(6)Type B

  Record centrally stored prescriptions and refill data

  87465 Incidental Medical and Dental Care(h) The following requirements shall apply to medications which are centrally stored:(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:This requirement is not met as evidenced by: Based on observation and record review, R1's 5 out of 10 centrally stored medications and R2's 6 out of 6 centrally stored medications were not recorded on the Centrally Stored Medication log which poses a potential health, safety or personal rights risk to persons in care.

• 87468(b)(1)(A)Type B

  Signed rights acknowledgement in resident record

  87468 (b)(1)(A)The licensee shall have each resident and the resident's representative sign a copy of these rights, and the signed copy shall be included in the resident's record.This requirement is met as evidenced by: Based on interview and record review, R2's file did not contain a signed Personal Rights of Residents in All Facilities which poses a potential health, safety or personal rights risk to persons in care.

• 87705(f)(1)Type A

  Notify agency before locking doors or gates

  87705 Care of Persons with Dementia(f) The following shall be stored inaccessible to residents with dementia:(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).This requirement is not met as evidenced by: Based on observation, LPAs observed more than 5 tools were in the backyard, not locked and accessible to residents with Dementia poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.