Comfort Haven for the Elderly

Based on interview, record review, the licensee did not comply with the section cited above in the facility only performed two drills last year and have not record, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observarion, interview and record reveiw, the licensee did not comply with the section cited above in one out of three medication reviews, discontinued medication was noted as given to a resident, which poses an immediate health, safety or personal rights risk to persons in care.

Based on interveiw and record reveiw, the licensee did not comply with the section cited above in one out of two visits by a nurse or consultant pharmacist, which poses/posed a potential 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 has not been met as evidenced by: Based on observations and interviews, Licesee did not ensure that auditory devices were on to monitor exits which poses an immediate health and safety or personal rights risk to residents with dementia in care.

87219 Planned Activities (a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities.Ths requirement has not been met as evidenced by: Based on interviews and observations, Licensee did not ensure that there are activities at the facility which poses a potential health and safety or personal right risks to residents in care.

87555 General Food Service Requirements (b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.This requirement has not been met as evidenced by: Based on observations and interviews, Licensee did not ensure that there were at least 2 days of perishable foods at the facility, facility did not have fresh fruit. which poses an immediate health and safety or personal right risk to all residents in care.

87211 Reporting Requirements (a)(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...(D) Any incident which threatens the welfare, safety or health of any resident...This requirement was not met as evidenced by: Based on records review, Licensee did not report an incident (occurred 2/25/2021) to CCLD within 7 days which poses a potential health and safety risk to 2 of 2 clients in care.

87555 General Food Service Requirements (b)(25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies. This requirement was not met as evidenced by: Based on observation, Licensee did not store cleaning materials separate from food supplies (found in ice chest) which poses an immediate health and safety risk to all residents in care.

87555 General Food Service Requirements (b)(8) All food shall be of good quality. This requirement was not met as evidenced by: Based on observation, Licensee did not to maintain food of good quality, rotten food found, which poses an immediate health and safety risk to all residents in care.

87618 Oxygen Administrator - Gas and Liquid (b)(3)(B) "No Smoking-Oxygen in Use" signs shall be posted in the appropriate areas. This requirement was not met as evidenced by: Based on observation, Licensee did not ensure that there were proper precaution signs for oxygen use in resident room #18 and #22 which poses a potential health and safety risks for all residents in care.

87705 Care of Person of Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, ...cleaning supplies and disinfectants. This requirement was not met as evidenced by: Based on observation, Licensee did not keep cleaning and disinfectants inaccessible to dementia residents in care which poses an immediate health and safety risk to residents in care.

87411 Personnel Requirements - General (f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. This requirement was not met as evidenced by: Based on staff records review, Licensee did not ensure that 1 of 1 staff (S3) obtain a complete TB test which poses a potential health and safety risk to all residents in care.

87412 Personnel Records (c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement was not met as evidenced: Based on records review, Licensee did not maintain Continuing Education Units (4 of 4 staff) and Orientation completion verification (3 of 4 staff) which poses a potential health and safety risk for all residents in care.

87465 Incidental Medical and Dental (h)(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:(A) The name of the resident for whom prescribed.(B) The name of the prescribing physician.(C) The drug name, strength and quantity.(D) The date filled.(E) The prescription number and the name of the issuing pharmacy.(F) Instructions, if any, regarding control and custody of the medication.this requirement was not met as evidenced by: Based on resident medication review, Licensee did not completely fill out 1 of 1 resident's (R1) medication centrally stored medication log which poses a potential health and safety risk for 1 of 1 resident in care.

87555 General Food Service Requirements (b)(27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement was not met as evidenced by: Based on observation, Licensee did not ensure that kitchen area was free of flies (observed fly strip trap hanging from ceiling) which poses a potential health and safety risk to all residents in care.

87212 Emergency Disaster Plan (a) Each facility shall have a disaster and mass casualty plan of action. This requirement was not met as evidenced by: Based on facility records review, Licensee did not maintain a complete and up-to-date Emergency Disaster Plan (LIC 610E) which poses a potential health and safety risk to all residents in care.

87307 Personal Accommodations and Services (a)(3)(C) The use of common wash cloths and towels shall be prohibited. This requirement was not met as evidenced by: Based on observation, Licensee did not prevent the use of a shared common hand towel for 2 of 2 clients which poses an immediate health and safety risk for 2 of 2 residents in care.

87411 Personnel Requirements - General (c)(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement was not met as evidenced by: Based on staff records review, Licensee did not ensure that 1 of 1 resident (S1) maintain an active first aid/CPR certificate which poses a potential health and safety risk to all residents in care.

87465 Inciental Medical and Dental (a) The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (5) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on medication review, Licensee did not provide medication assistance for R4 (missing 11 pills) which poses an immediate health and safety risk to 1 of 1 resident in care.

87465 Incidental Medical and Dental (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. This requirement was not met as evidenced by: Based on resident medication reveiw, Licensee did not destroy left over medication and equipment for 1 of 1 resident (R2) which poses a potential health and safety risk to all residents in care.

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility...this requirement was not met as evidenced by: Based on resident records review, License did not maintain a complete and current records for 6 of 6 residents which poses a potential health and safety risk for 6 of 6 residents in care.

87555 General Food Service Requirements (b)(21) Freezers of adequate size shall be maintained at a temperature of 0 degrees F (-17.7 degrees C), and refrigerators of adequate size shall maintain a maximum temperature of 40 degrees F (4 degrees C). This requirement was not met as evidenced by: Based on observation, Licensee did not ensure that facility refrigerator and freezer have a thermometer which poses a potential health and safety risk to all residents in care.

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met as evidenced by: Based on observation, Licensee did not maintain inspection service for one fire extinguisher, last inspected 2015, and have facility ansul system operational which poses an immediate health and safety risk to all residents in care.

87303 Maintenance and Operations (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: Based on observation and service reports obtained, Licensee did not keep the facility air conditioner in good repair and did not keep facility free of cockroaches which poses an immediate health and safety risk for all residents in care.

87207 False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met as evidenced by: Based on statements, Licensee made false statements to RM, LPM, and RM during a conference call which poses an immediate health and safety risk to residents in care.

87468.1 Personal Rights (a)(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on observation and records review, Licensee did not follow facility COVID-19 screening protocols which poses an immediate health and safety risk to all clients in care.