L & S Gentle Care Ii

87506 Resident Records(a) The licensee shall ensure that a...complete... record is maintained for each resident in the facility...readily.. for.. licensing staff.This requirement is not met as evidence by: Based on observation, record review and interview, the licensee did not comply in four(4) out of five (5) resident records missing signed personal rights and/or consent for emergency medical treatment which poses a potential health, safety and personal rights risk to persons in care.

Based on observation, interview and record review the licensee did not comply with the section cited above in three (3) out of four (4) residents which poses an immediate health, safety or personal rights risk to persons in care.

569.625(b)(2)…[T]raining requirements shall...include an additional 20 hours annually….This requirement is not met as evidenced by; Based on observation and record review, the licensee did not comply with the section cited above in ensuring that S1 has proof of required annual training which poses a potential health, safety, and personal rights risk to persons in care.

1569.69(b) Each employee...who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period. Based on observation and record review, the licensee did not comply with the section cited above in ensuring that S1 has proof of required annual medication training which poses a potential health, safety, and personal rights risk to persons in care.

87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Based on observation, interview, and record review, the licensee did not comply with the section cited above for S1, S2, S3, S4, S5, S6, S7, S9, and S10 whose files were all missing one or more required documents which poses a potential health, safety, and personal rights risk to persons in care.

87307 Personal Accommodations and Services: (a) ....The facility shall...provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. This requirement is not met as evidenced by: Based on observation and interviews the Licensee did not ensure that staff who may reside or sleep in the facility are provided private accommodations within the scope of their fire clearance which poses an immediate health, safety, and personal rights risk to persons in care.

. 87405 Administrator - Qualifications and Duties: (a)....The administrator...shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility....This requirement is not met as evidenced by: Based on observation, interviews, and record review, the licensee did not comply with the section cited above in ensuring compliance and by having untrained staff working independently which poses a potential health, safety, and personal rights risk to persons in care.

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training....This requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee did not comply with the section cited above for S1 and S2 who Licensee stated were hired the day prior, 9/18/2024 and who LPA observed working independently with residents which poses a potetnial health,

87506 Resident Records: (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee did not comply with the section cited above for R1, R2, R4, and R5 whose files were all missing two or more required documents which poses a potential health, safety, and personal rights risk to persons in care.

87705 Care of Persons with Dementia f) The following shall be stored inaccessible to residents with dementia: (2) ...alcohol, ... and toxic substances such as certain..., gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Based on observation Licensee did not ensure that alcohol, cleaning solutions, and chemicals were kept in a secure place that is not accessible to residents, which poses an immediate health, safety, and personal rights risk to persons in care.

§1569.69 Employees assisting residents with self-administration of medication; training requirements:a) ... 2) ...the employee shall complete...two hours of hands-on shadowing training...prior to assisting with the self-administration of medications....This requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee did not comply with the section cited above for S1 and S2 who addmitedly gave medications on the morning of 09/19/2024 without completing any medication training which poses a

Based on observation, interview, and record review, the licensee did not comply with the section cited above in 2 out of 3 resident records reviewed which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, interview, and record review, the licensee did not comply with the section cited above in 2 out of 5 staff files reviewed which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 1 records reviewed which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, interview, and record review, the licensee did not comply with the section cited above in 2 out of 3 resident files reviewed which poses an immediate health, safety or personal rights risk to persons in care.

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training...This requirement is not met as evidenced by: Based on LPA and Admin observation staff memeber S1 did not have their annual training current or completed.

87465(h)(2) Incidental Medical and Dental Care: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees...This requirement is not met as evidenced by: Based on LPA observation medication closet housing centrally stored medications was left unlocked, which poses a potential health, safety or personal rights risk to persons in care.

Based on observation and interview, the licensee did not comply with the section cited above in that the water temperature tested in resident's bathrooms was 132 degrees F, this 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 in 5 staff who do not have health screening and TB test completed as required. This poses/posed a potential health, safety or personal rights risk to persons in care.

Based on interview & record review, the licensee did not comply with the section cited above in 1 out of 6 residents (Residet R3). This poses/posed a potential 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 in 5 staff who do not have any initial or annual training documented or completed. This poses/posed a potential health, safety or personal rights risk to persons in care.

Based on interview & record review, the licensee did not comply with the section cited above in 1 of 6 residents (R1). This poses/posed a potential health, safety or personal rights risk to persons in care.

87466 Observation of the Resident : The licensee shall ensure that residents are regularly observed for changes in physical... functioning and that appropriate assistance is provided when such observation reveals unmet needs... (continued --->) Based on record review and interviews conducted: Facility staff failed to ensure proper care & supervision for R1 which resulted in R1 sustaining a stage 3 pressure injury. This is an immediate health, safety and personal rights risk to the residents in care.

87615 Prohibited Health Conditions: (a) Persons who require health services... specified below shall not be admitted or retained in a residential care facility for the elderly: (1)Stage 3...pressure injuries. This requirement was not met as evidenced by: Based on record review and interviews conducted: Administrator did not ensure the above regulation due to Resident (R1) sustaining a stage 3 pressure injury while in care and Admin did not request or was approved for an exception from CCL to retain R1 with a prohibited condition. This is a potential health, safety and personal rights risk to the residents in care.

87211 Reporting Requirements:(a) Each licensee shall furnish...:(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...(B) Any serious injury...occurring while the resident is under facility supervision. This requirement was not met as evidenced by: Based on record review and interviews conducted: Administrator did not ensure ensure both R1's responsible person and Licensing were notified of R1's injury to mouth/teeth and pressure injuries within the timeframe as required. This is a potential health, safety and personal rights risk to the residents in care.

87456 Evaluation of Suitability for Admission: (a)Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall...(2) Perform a pre-admission appraisal.This requirement was not met as evidenced by: Based on record review and interviews conducted: Administrator did not ensure Resident (R1) was properly assessed with a pre-admission appraisal as required. This is a potential health, safety and personal rights risk to the residents in care.

§1569.269 Enumerated rights; severability: (a) Residents...shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs and are delivered by staff... to meet their needs. This requirement was not met as evidenced by: Based on record review and interviews conducted: Facility staff failed to ensure R1 received medical services in a timely manner after R1 sustained an injury to their mouth & pressure injuries (one stage 3). This is an immediate health, safety and personal rights risk to the residents in care.

87224 Eviction Procedures:(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required...This requirement was not met as evidenced by: Based on record review and interviews conducted: Administrator did not ensure the above regulation due to issuing a verbal eviction notice to R1's representative and not following proper eviction procedures. This is a potential personal rights risk to the residents in care.

87468.1 Personal Rights of Residents in All Facilities: (a) Residents... shall have all of the following personal rights:(11) To have their visitors...permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This requirement was not met as evidenced by: Based on record review and interviews conducted: Licensee did not ensure the above regulation due to changing visitation hours to discourage R1's representative from visiting regularly. This is a potential personal rights risk to the residents in care.

87355 Criminal Record Clearance - (e) All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility:(2) Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement was not met as evidenced by: Based on record review, observation, and interviews conducted: Administrator did not associate individual (I1) prior to working, residing or being present in the facility.This is a potential safety and personal rights risk to the residents in care.

87208 Plan of Operation:(c) A licensee who accepts or retains residents diagnosed by a physician to have dementia shall include additional information in the plan of operation as specified in Section 87705(b). This requirement was not met as evidenced by: Based on record review, observation, and interviews conducted: Administrator did not ensure the regulation above due to not having an approved dementia program care plan prior to accepting and retaining residents with a diagnosis of dementia.This is a potential safety and personal rights risk to the residents in care.

87202 Fire Clearance:(a) All facilities shall ...Prior to accepting or retaining any of the following types of persons...obtain an appropriate fire clearance approved by the city...fire department...(1) Nonambulatory persons. This requirement was not met as evidenced by: Based on observation, interviews, and record review - Administrator did not ensure the regulation above due to having 4 non-ambulatory residents (R1-R4) in bedrooms that are not approved for non-ambulatory residents. This is an immediate health & safety risk to residents in care.

87608 Postural Supports - (a) ... the facility shall provide assistance and care for the resident...(1) Postural supports shall be limited to appliances or devices...used to achieve proper body position and balance, to improve a resident's mobility and independent functioning, or to position... This requirement was not met as evidenced by: based on observation, interviews, and record review, licensee did not ensure the regulation above with resident (R1) observed with a lap belt on wheelchair. This is a potential health, saftey and personal rights risk to residents in care.

87355 Criminal Record Clearance - (e)All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility:(2) Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement was not met as evidenced by: Based on record review, observation, and interviews conducted: Licensee did not obtain a criminal record clearance for individual (I1) prior to working at the facility.This is a potential safety risk to the residents in care.

87608 Postural Supports -(a)...the facility shall provide assistance and care for the resident...(5) ...(B) Bed 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 requirement was not met as evidenced by: based on observation, interviews, and record review, licensee did not ensure the regulation above with resident (R2) observed with full bed rails. This is a potential health, saftey and personal rights risk to residents in care.

87309 Storage Space - (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met as evidenced by: Based on observation and interviews, Licensee did not ensure cleaners and disinfectants were stored locked and inaccessible to residents.This is an immediate health & safety risk to the residents in care.