Complaint·November 7, 2024

Citations

5 citations recorded^*CCLD

• 87211(a)(1)Type B

  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...within seven days of the occurrence of any of the events specified in (A) through (D) below...This requirement is not met as evidenced by: Based on interview conducted with the General Manager at the time, there was an incident that occurred on 4/6/22 where R2 complained of a facility caregiver being abusive. The General Manager at the time admitted to not filing an incident report to CCLD for unknown reasons which poses a potential health and safety risk for residents in care.

• 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...This requirement is not met as evidenced by: Based on observations LPA observed the top door hinge to be loose, a sign on the door stating disrepair and a nail in a ziplock bag from the missing nail on the door hinge. In addition, based on interviews conducted, it was indicatd that the door has been in disrepair for more than 2 months.

• 87465(h)(5)Type B

  Keep prescriptions in original containers

  87465 Incidental Medical and Dental Care:(h) The following requirements shall apply to medications which are centrally stored:(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.This requirement has not been met as evidenced by: Based on observations made during the visit conducted on 4/20/2022, LPA observed facility to be pre-pouring medication in plastic organizers or small cups labeled for morning and with bedroom numbers. The medication observed were being dispensed in small cups for 24 to 48 hours in advance. Nevertheless, the facility is transferring residents' medications from the originally received container to small cups.

• 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 observations and record review, LPA and Med-tech observed 8 packs of Acetaminophen in the overstock cabinet to not be logged on the Centrally Stored Medication Record (CSMR). In addtion, LPA observed R1's eye drop not logged on the CSMR.

• 87465(i)Type B

  Dispose of unused medications with required witness

  87465 Incidental Medical and Dental Care: (i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident... Based on observations, on 4/20/22, LPA observed a bin full of medication that needed to be destructed. In addition, on 11/7/24, LPA observed a full box of medications that needed to be destructed.