Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |  |
Type A
03/03/2022
Section Cited
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2
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4
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6
7 | Prohibited Health Conditions
(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly:(4) Staphylococcus aureus ("staph") infection or other serious infection. This requirement was not met as evidenced by LPAs observation and records review, R1 had a serious infection that is a prohibited health condition and facility did not submit an exception for this condition. This poses an immediate Health, Safety or personal risk to residents in care. *Immediate Civil Penalty is assessed*
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Type A
03/03/2022
Section Cited
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2
3
4
5
6
7 | Colostomy/Ileostomy
...the licensee shall be permitted to accept or retain a resident who has a colostomy...under the following circumstances: (1)If the resident is mentally and physically capable of providing all routine care for his/her ostomy, and the physician has documented that the ostomy is completely healed. This requirement was not met as evidenced by interviews with | | | |
| 8
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14 |
staff stating the facility provides care for Resident 2's colostomy bag. This poses an immediate Health, Safety or personal risk to residents in care.
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14 | | |
| 1
2
3
4
5
6
7 | | | | |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) | |
Type A
03/03/2022
Section Cited
| 1
2
3
4
5
6
7 | 87608 Postural Supports
(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet.(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 by LPAs observation of R13 and R14's full bed rails. This poses an immediate Health, Safety or personal risk to residents in care.
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9
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14 | | 8
9
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13
14 | | |
Type A
03/03/2022
Section Cited
| 1
2
3
4
5
6
7 | Administrator - Qualifications and Duties (h) The administrator shall have the responsibility to:
(1) Administer the facility in accordance with these regulations and established policy, program and budget. This requirement was not met as evidenced by the substantial noncompliance which poses an immediate health, safety or personal rights risk to residents in care.
87405(h)(1)
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5
6
7 | | | | |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) | |
Type A
03/03/2022
Section Cited
| 1
2
3
4
5
6
7 | 87631 Healing Wounds
(a) Except as specified in Section 87611(a), the licensee shall be permitted to accept or retain a resident who has a healing wound under the following circumstances:(3) Residents with a stage one or two pressure injury must have the condition diagnosed by a physician or an appropriately skilled professional.(A) The resident shall receive care for the pressure injury from a physician or an appropriately skilled professional. This requirement was not met as evidenced by Staff are providing wound care for R15 and R19 and are not appropriately skilled professionals. This poses an immediate Health, Safety or personal risk to residents in care.
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Type A
03/03/2022
Section Cited
| 1
2
3
4
5
6
7 | 87633 Hospice Care of Terminally Ill Residents
(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility when all of the following conditions are met:(4) A written hospice care plan which specifies the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the facility is developed for each terminally ill resident or prospective resident by that resident’s hospice agency and agreed to by the licensee and the resident, or prospective resident, or the resident’s or prospective resident’s Health Care Surrogate Decision Maker, if any, prior to the initiation of hospice services in the facility for that resident, and all hospice care plans are fully implemented by the licensee and by the hospice(agency).
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14 | This requirement was not met as evidenced by LPAs request for Hospice Care Plans for residents in care. The facility was unable to provide documentation on 2/28/22 for Resident R4, R16, R17 and R18. This poses an immediate Health, Safety or personal risk to residents in care. | 8
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14 | | |
Type A
03/03/2022
Section Cited
| 1
2
3
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5
6
7 | 87609 Allowable Health Conditions and the Use of Home Health Agencies
(b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met:(4) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident’s medical condition(s).(C) The written agreement shall be signed by the licensee or licensee representative, and representative of the home health agency, and placed in the resident’s file. This requirement was not met as evidenced by LPAs request for Home Health care plans on 2/28/22 and facility was unable to provide for Resident R1, R15, and R19. This poses an immediate Health, Safety or personal risk to residents in care.
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) | |
Type A
03/02/2022
Section Cited
| 1
2
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4
5
6
7 | 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.
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14 | This requirement was not met as evidenced by Based on LPA's observation R20's room had a can of lysol on the dresser which poses and immediate, health, safety, or personal rights risk to residents in care. | 8
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Type B
03/18/2022
Section Cited
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7 | 87303 Maintenance and Operation (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 (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.
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14 | This requirement was not met as evidenced by Based on LPA's observation R21 and R22's room smelled of urine. This poses an potential Health, Safety or personal risk to residents in care. | 8
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