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32 | [CONTINUED FROM LIC 809-C, 1 of 3] During the visit, LPA observed, and manager interview confirmed: Licensee did not ensure the facility’s three (3) fire extinguishers had been professionally inspected and serviced within the last twelve (12) months, which was needed to remain in ongoing compliance with the facility’s prior-approved fire clearance. Also, Licensee did not ensure that a working “auditory device or other staff-alert feature to monitor exits” was present on two (2) of the four (4) exterior exit-doors which residents had access to (which is required when caring for persons with Dementia).
During a review of client records, LPA observed, and manager interview confirmed: R4’s doctor wrote that on their LIC602 Physician’s Report (dated 06-08-2023) that they did not have Tuberculosis (TB). However, Licensee did not have written proof of a negative TB test result or chest X-ray for R4, which was required before R4 moved-in. [During the inspection, R4 did not show signs/symptoms, observable to the layperson, of active TB infection] For R2, R4, R5, and R6, Licensee did not ensure they had a LIC602 Physician’s Report (or equivalent Medical Assessment) updated within the last year, which was required for residents diagnosed with Dementia. For R1 through R6, Licensee did not complete a Functional Capabilities Assessment (or equivalent determination of the resident's ability to perform specified activities of daily living), as required. For R1 through R6, Licensee did not complete a Needs and Services/Care Plan (or equivalent “written record of care the resident will receive in the facility [and] the resident’s preferences regarding the services provided at the facility”), as required. There was also no evidence that Licensee held a care conference meeting with the respective responsible persons (RPs) for R1 through R6, within the last twelve (12) months, as was required. For R1 through R6, Licensee did not ensure their care records contained the name, address, and telephone number of a dentist to be called in an emergency, as required. For R1 through R6, Licensee did maintain a Personal Property Inventory, which was required to be completed with the resident and/or their representative at time of move-in. For R2, R3, R4, and R6, Licensee did not maintain a copy of the Resident’s Personal Rights, signed by the resident and/or their representative, in the resident’s record, as required. For R1 and R5, there was a copy of signed Resident’s Personal Rights, but the version of the form used was outdated/obsolete, and thus incomplete. For R1 through R6, Licensee did not maintain a Telecommunications Device Notification form, signed by the resident and/or their representative, as required. Also, Licensee did not maintain a record of body weights for R1 through R6. (Regulation required Licensee to “regularly observe” clients for changes in physical condition, to include “unusual weight gains or losses.”)
[CONTINUED ON LIC 809-C, 3 of 3] |