White Rose Manor

Based on LPA observation, the licensee did not comply with the section cited above in that R1 has full bed rails on bed but no exception on file, which poses a potential health, safety or personal rights risk to persons in care.

Health screening and fitness requirements

Based on LPA record review, the licensee did not comply with the section cited above in that S6 did not have a health screen or TB clearance on file, which poses a potential health, safety or personal rights risk to persons in care.

Based on LPA record review, the licensee did not comply with the section cited above in that S6 did not have any training completed on file, which poses a potential health, safety or personal rights risk to persons in care.

Based on LPA record review, the licensee did not comply with the section cited above in that S3, S4, and S5 did not have required restricted conditions training, which poses a potential health, safety or personal rights risk to persons in care.

Based on LPA record review, the licensee did not comply with the section cited above in that S5 and S6 did not have 10 hours of initial medication training, which poses a potential health, safety or personal rights risk to persons in care.

Based on LPA record review, the licensee did not comply with the section cited above in that S3 and S4 did not have 8 hours of in-service medication training completed, which poses a potential health, safety or personal rights risk to persons in care.

Encourage resident participation in varied planned activities

Based on LPA observation, the licensee did not comply with the section cited above in that LPA observed residents lying in bed staring at the wall or ceiling. No activites provided. LPA did not observe residents engaged in any activities for the duration of both LPA's visits, which poses a potential health, safety or personal rights risk to persons in care.

Food handling safeguards during storage and service

Based on LPA observation, the licensee did not comply with the section cited above in that LPA observed carton of 150 eggs left outside of refrigeration inside garage in 96 degree F heat, which poses a potential health, safety or personal rights risk to persons in care.

Food storage temperature control requirements

Based on LPA observation and interview, the licensee did not comply with the section cited above in that LPA observed refrigerator in garage containing food to not be cool and was leaking, no thermostat present, so no temperature reading available. Facility has two [2] refrigerators and one freezer. Per designee, the other refrigerator has also been leaking and licensee is aware, which poses a potential health, safety or personal rights risk to persons in care.

Based on LPA interview, the licensee did not comply with the section cited above in that R1 reported they were confined to their room during the hours of 1pm-3pm, which poses a potential health, safety or personal rights risk to persons in care.

Address and clearance obligations before facility work

Based on LPA interview and record review, the licensee did not comply with the section cited above in S2 did not have fingerprint clearance, which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPA observation and record review, the licensee did not comply with the section cited above in that R1 had prescription for Doxycycline Monohydrate 100mg, that was not listed on the Centrally Stored Medication Log (CSML) and R3 did not have a CSML, which poses an immediate health, safety or personal rights risk to persons in care.

Store centrally held medications in locked secure place

Based on LPA observation, the licensee did not comply with the section cited above in thatt LPA observed medication cabinet to be open and unlocked, which poses an immediate health, safety or personal rights risk to persons in care.

Maintain facility in clean, safe, sanitary condition

Based on LPA observation and interview, the licensee did not comply with the section cited above in that tile around kitchen sink is in disrepair and showing areas of black and gray substance, under kitchen sink mold all over: plywood has mold and has rotted, sides of the cabinet have mold, garbage disposal is rusted, and water lines rusted, which poses a potential health, safety or personal rights risk to persons in care.

Notify agency before locking doors or gates

Based on LPA and Designee's observation, the licensee did not comply with the section cited above as lock on knife drawar in kitchen was broken (see pics), and cleaning supplies (bleach) (see pic) were in garage, unlocke & detergent was in uncovered cup under sink in resident bathroom which poses an immediate health, safety or personal rights risk to persons in care.

Store centrally held medications in locked secure place

Based on observation, the licensee did not comply with the section cited above in 6 out of 6 residents which poses an immediate health, safety or personal rights risk to persons in care. LPA observed during tour of the facility medications in unlocked medication refrigerator. (see pictures)

Separate storage for cleaning chemicals

Based on observation the licensee did not comply with the section cited above in 1 out of 1 cabinet under kitchen sink contained cleaning products and onions, potatoes, and other food items etc.. which poses/posed a potential health, safety or personal rights risk to persons in care. Designee immedicately removed cleaning products to locked garage cabinet.

Review and revise record after changes

Based on record review the licensee did not review & update the written needs & care assessment in the last 12 months in 4 of 6 residents which poses a potential health, safety risk to residents in care. LPA review records for resident R1, R2, R3, & R4 and learned that needs &services plans all dated 2022..

This requirement is not met as evidenced by: Based on interview, the licensee did not comply w/section cited above in 1 of 1 facility drill which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on residents' file review the licensee did not have annual medical assessment (602) for 1 out of 4 residents w/ dementia which poses a potential health, safety risk to residents in care. LPA reviewed files for residents on 1/3/24 and learned that R1's last Physicians assessment was on 10/25/2022.

Maintain fire clearance before retaining specified persons

Based on observation, the Licensee/Administrator did not comply with the section cited above in 1 out of 1 fire extinguisher was not serviced since January 24, 2022 which poses an immediate health, safety or personal rights risk to persons in care.

Store centrally held medications in locked secure place

Based on LPA's observation of medicaiton in 2 unlocked kitchen drawers, medications are accessible to residents in care. This is an immediate Health and Safety risk to residents in care.