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25 | On 2-1-23 at 10:23am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a quarterly health and safety check. LPA met with Administrator Adetayo Kokumo and explained the purpose of the visit. Health and Safety check is conducted based on a previous informal conference held originally on 10-27-22.
LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. Facility is a 6-bed residential facility for the elderly with a current census of 3. LPA was screened upon entry for temperature and asked to sign in. COVID screening questions were asked prior to entry. Facility has 6 bedrooms and 3 bathrooms. There is a formal living room and family/TV room for residents. All knives, toxins, and other chemicals were inaccessible to residents in care. Resident rights posted. No obstructions to emergency exits noted.
The facility has submitted a COVID mitigation plan. The facility has central entry point and has implemented screening and sign in procedures at the front door area. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door, and back yard. The facility has a designated infection control lead. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use. LPA observed all staff to be wearing masks during visit. LPA observed facility to be clean and sanitary with no foul odors. There were 2 staff on duty during LPA's visit today. Water temperature reads between 105*F and 120*F in the bathroom and room temperature reads 78*F. LPA observed the facility to have adequate food supply during today’s visit. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. {Cont. on 809C} |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
02/10/2023
Section Cited
HSC
1569.625(d)(1)
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7 | (d) This section shall not apply to certified nurse assistants...(1) A licensed or certified health professional with valid certification shall receive eight hours of training on resident characteristics, resident records, and facility practices and procedures prior to providing direct care to residents. This requirement is not met as evidenced by: | 1
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7 | Licensee will complete required staff training for S3 and submit proof of completed training to LPA by POC due date.
Licensee will read regulation 1569.625 and submit a signed declaration of understanding to LPA by POC due date. |
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14 | Based on record review, training requirements for resident characteristics, resident records, and facility practices and procedures were not completed for S3 by licensee. S3 is a certifiied nursing assistant hired in November of 2022. This poses a potential health and safety risk to residents in care. | 8
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14 | Licensee will complete required dementia care training for S3 and submit proof of completed training to LPA by POC due date. |
Type B
02/10/2023
Section Cited
HSC1569.625(d)(2)
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7 | (d) This section shall not apply to certified nurse assistants..(2) In addition to paragraph (1), a certified nurse assistant shall also receive the 12 hours of dementia care training specified in Section 1569.626..This requirement is not met as evidenced by:. | 1
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14 | Based on record review, S3, a certified nursing assistant did not receive required dementia training by licensee. S3 was hired in November of 2022. This poses a potential health and safety risk to residents in care. | 8
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