Our Home Llc

Ensure hazardous items are locked and not unattended

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 not met by licensee as evidenced by: Based on LPA and Admin observation, pre-poured medication present on kitchen island counter, which poses an immediate health, safety or personal rights risk to persons in care.

Facility must keep complete hospice care plan on file

87633 Hospice Care of Terminally Ill Residents (b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: This requirement not met by licensee as evidenced by: Based on LPA and Admin obsevation, hospice care plan not on file for R1, which poses a potential health, safety or personal rights risk to persons in care.

Right to personal privacy in daily care

Based on LPA and licensee observation and interview, the licensee did not comply with the section cited above in that video survelliance with audio was found in the common areas inside and outside the facility, which poses a potential health, safety or personal rights risk to persons in care.

Provide resident hot water for personal care

Based on LPA and licensee observation, the licensee did not comply with the section cited above in that water temperature in sink accessible to residents in care measured at 94.5 in bathroom between rooms #4 and #5 and 102.9 degrees F in bedroom #3, which poses a potential health, safety or personal rights risk to persons in care.

Ensure hazardous items are locked and not unattended

Based on LPA and licensee observation, the licensee did not comply with the section cited above in that licensee and LPA observed butcher knife left unattended on kitchen island with residents present less than 2 feet away at dining table which poses a potential health, safety or personal rights risk to persons in care.

Assist residents with self-administered medication

Based on LPA and licensee observation and record review, the licensee did not comply with the section cited above in that count of Quetiapine for R1 did not match Centrally Stored Medication Log, which poses an immediate health, safety or personal rights risk to persons in care.

Fire approval and staff access to unlock systems

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia (2) Over-the-counter medication, nutritional supplements or vitamins... This requrement was not met by licensee as evidenced by: Based on LPA interview with Admin medication pills have been found on the floor of the facility, which poses a potential health, safety or personal rights risk to persons in care.

87705 Care of Persons with Dementia (l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (6 Locked exterior doors or perimeter fences with locked gates shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents. This requriement was not met by licensee as evidenced by: Based on LPA interview and observation facility had sliding lock present on bottom of front door to address sundowning behavior and attempted elopment of resident..

Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that R1 has diagnosis of dementia, but most recent physician's report dated 5/15/2023 did not have all pages present, last page with doctor signature line not present, the next most current physician's report dated 2020. R1's most recent appraisal dated 5/5/2023, which poses a potential health, safety or personal rights risk to persons in care.

Food quality controls and rejected damaged goods

Based on LPA, caregiver, and Admin observation, the licensee did not comply with the section cited above in that refrigerator drawer of radishes were covered in black substance and spots. Refrigerator drawer liner covered with black spots of a black substance and contained wilted and browning celery with brown liquid, and lemon and orange with white and blue fuzzy substance, which poses a potential health, safety or personal rights risk to persons in care.

Fire approval and staff access to unlock systems

Based on LPA and caregiver observation, the licensee did not comply with the section cited above in that one [1] of two [2] main bathrooms had cabinet containing toxins not locked but had locking function, which poses a potential health, safety or personal rights risk to persons in care.

Based on LPA and Admin record review, the licensee did not comply with the section cited above in that S2 did not have current training completed, 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 with Admin and LPA record review, the licensee did not comply with the section cited above in that S1 did not have fingerprint clearance. Per Guardian, the fingerprint clearance status of S1 is "in process," but not yet showing a determination of eligible clearance which poses an immediate health, safety or personal rights risk to persons in care.

Label and preserve medicine compliance standards

A spot check of medications revealed that centrally stored medications log has discrepancies and one omission of dates filled and prescription numbers.

Maintain facilities for fire and panic safety

Based on LPA observation the licensee did not comply with the section cited above in [2] out of [3] fire extinguishers which poses/posed a potential health, safety or personal rights risk to persons in care.

Document behavioral expression and related causes

Based on LPA record review, the licensee did not comply with the section cited above in [3] out of [6] care plan for residents (R1, R2 & R3) which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPAs record review, the licensee did not comply with the section cited above in [2] out of [5] staff CPR/training records were not updated, which poses/posed a potential health, safety or personal rights risk to persons in care.