Kingdom Hearts Care Home

Update reappraisal at required intervals

87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary...shall document changes in the resident's physical, medical, mental, and social condition...This requirement was not met as evidenced by; Based on document review and investigation, R1's needs and services plan was not updated after R1 had eloped from the facility. The facility did not update the care plan for R1 to meet his/her needs. This poses an immediate risk to the health of the resident.

Passageways and stairways kept clear

87307 Personal Accommodations and Services (d)(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.This Requirement was not met as evidenced by; Based on interviews and observation, Resident R1's bedroom had a couch obstructing the exit outside. ADM, S1 and S2 admitted they obstructed R1's sliding screen door and the front door of the facility due to R1's exit seeking behaviors.

Conformance with applicable laws and regulations

87405 Administrator - Qualifications and Duties (d)(2) Knowledge of and ability to conform to the applicable laws, rules and regulations.This Requirement was not met as evidenced by; Based on records reviewed and interviews conducted, Administrator did not exhibit the knowledge of applicable laws, rules and regulations resulting in serious violations involving a resident who eloped from facility which poses an immediate health safety and personal rights risk to persons in care.

Allow licensing inspection and controlled record removal

87412 (f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying... This requirement was not met as evidenced by; Based on interview conducted, LPA requested to review staff dementia training records. ADM stated the records were at her home and unavailable for LPA to inspect. This poses/posed a potential health, safety or personal rights risk to persons in care.

Safe, healthful, comfortable accommodations

87468.1 Personal Rights of Residents in All Facilities (a)(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This Requirement was not met as evidenced by: Based on interviews and observation, Resident R1's bedroom sliding door was blocked with a couch and a stick. ADM, S1 and S2 stated this was done to prevent R1 from exiting his/her bedroom. This poses/posed an immediate health, safety or personal rights risk to persons in care.

Right to sufficient care and qualified staff

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(4) To care, supervision, and services that meet their individual needs ... by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by; Based on interviews conducted, resident R1 had elopped from the facility on July 19, 2024 and staff did not provide R1 with Care and Supervision to met his/her needs. This poses an immideate threat to health, safety or personal rights risk to persons in care.

87705 Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.This Requirement was not met as evidenced by; Based on observation, Resident bedrooms 2-5's sliding doors alarms were turned off. Based on record review, resident R1 cannot leave the facility unassisted and he/she has exit seeking behavior. This poses/posed an immediate health, safety or personal rights risk to persons in care.

87705 Care of Persons with Dementia (k)(7) For each incident in which a resident wanders away from the facility unsupervised...The report shall be made by telephone no later than the next working day and in writing within seven calendar days. This Requirement was not met as evidenced by; Based on interview with ADM, the ADM admitted that she did not contact community care licensing to make a report the next working day. ADM stated she did not know she had to call in to make a report. This poses/posed an immediate health, safety or personal rights risk to persons in care.

Assist residents with self-administered medication

87465 Incidental Medical and Dental Care (a)(4) The licensee shall assist residents with self administered medications as needed.This requirement was not met as evidence by: Based on record review and interviews conducted, R1’s medications had an excess of 55 pills. ADM acknowledged that there have been instances where 1 pill was given instead of 3 pills. This poses/posed a potential health, safety or personal rights risk to persons in care.

87211 Reporting Requirements (a)(1)(D) Any incident which threatens the welfare, safety or health of any resident..., or unexplained absence of any resident.This requirement was not met as evidenced by; Based on interview and records reviewed, R1 had sustained a fall in March 26, 2024. ADM stated she did not send an incident report for this fall. This poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review and interview, the ADM did not comply with the section cited above. Facility records state the last drill conducted was on 03/30/2023. ADM stated the facility was due for a drill. This poses/posed a potential health, safety or personal rights risk to persons in care.