HUMBLE HAVEN RCFE II

Official classification

Type B

Official code

1569.696(a)

Regulation authority

HSC

What the official deficiency says

(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observations of staff files, the licensee did not comply with the section cited above. The caregivers did not receive training when they began working at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/11/2025 Plan of Correction The Licensee will send a document stating the date the three staff members have completed the training. The Licensee will send the document to LPA Spaeth via email.

Official classification

Type B

Official code

1569.696(a)(1)

Regulation authority

HSC

What the official deficiency says

(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: (1) Four hours of training on the care, supervision, and special needs of those residents, prior to providing direct care to residents. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observations of staff files, the licensee did not comply with the section cited above. The caregivers did not receive training when they began working at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/11/2025 Plan of Correction The Licensee will send a document stating the date the three staff members have completed the training. The Licensee will send the document to LPA Spaeth via email.

Official classification

Type B

Official code

87506(b)(15)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's review of the resident's file, the licensee did not comply with the section cited above in one out of four resident files which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/11/2025 Plan of Correction The Administrator will send a copy of the signed Admissions Agreement for resident 1 (R!) to LPA Spaeth via email.

Official classification

Type B

Official code

1569.695(e)(2)

Regulation authority

HSC

What the official deficiency says

(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's review of the resident's file, the licensee did not comply with the section cited above in one out of four resident files which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/11/2025 Plan of Correction The Administrator will send a copy of the appraisal/needs assessment for resident 1 (R!) to LPA Spaeth via email.

Official classification

Type B

Official code

87705(e)

Regulation authority

CCR

What the official deficiency says

(e) Licensees that use delayed egress devices on exterior doors and perimeter fence gates shall meet the following initial and continuing requirements: This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observation, the licensee did not comply with the section cited above in two out of four egress devices which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/02/2025 Plan of Correction During LPA's visit, LPA observed a caregiver activated the egress device to the back door of the facility and replaced the broken egress device in the master bedroom (room 5)

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance & operation (e) Water supplies….shall be maintained..(2) Faucets used by residents for personal care…shall deliver hot water. Hot water temperature controls shall be …105 degree F (41 degree C) and not more than 120 degree F … This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observation, the licensee did not comply with the section cited above. The water temperature was 123 degrees F which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/02/2025 Plan of Correction During LPA's visit, the staff member adjusted the hot water temperature. LPA tested the water at 11:13 am and observed the temperature was 118 degreees F

Official classification

Type B

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications… (2) Centrally stored medicines shall be kept in a safe and locked place… This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observations, the licensee did not comply with the section cited above. LPA observed a resident's medications were not locked and the staff medications were not locked which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/02/2025 Plan of Correction During LPA's visit, LPA observed the resident's medications and the staff medications were safely locked.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements-General (f) All personnel…shall be in good health…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.ir duties… This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's review of staff records, the licensee did not comply with the section cited above. Three staff members have not completed a health screening which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/09/2025 Plan of Correction The Licensee will send the Health Screening Report (LIC 503) for the three staff members via email to LPA Spaeth

Official classification

Type B

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

87458 Medical Assessment (a) Prior to person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment... to be kept in the resident's record. This is evidenced by: The Licensee failed to obtain the Physician's Assessment (LIC 602) for Resident one, and resident 5. This poses an immediate health and safety risk to residents in care.

Official plan of correction

The Licensee will obtain the LIC 602 for resident one and 5. The Licensee will send a copy to LPA Spaeth via email.

Deadline recorded: Apr 4, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87507(a)

Regulation authority

CCR

What the official deficiency says

87507 Admissions Agreements (a) The licensee shall complete an individual written admission agreement… with each resident or the resident's representative, if any. This is evidenced by: The Licensee failed to obtain the Admissions Agreement for Resident two. This poses a personal rights violation to residents in care.

Official plan of correction

The Licensee will obtain the Admiissions Agreement for resident two. The Licensee will send a copy to LPA Spaeth via email.

Deadline recorded: Apr 4, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87761(b)(1)

Regulation authority

CCR

What the official deficiency says

87761 Penalties (b) Notwithstanding Section 87761(a) above, an immediate penalty of $100 per cited violation per day….shall be assessed…requested a transfer of a criminal record clearance…This is evidenced by: The Licensee failed to ensure a staff member had been associated to the facility. This poses an immediate health and safety risk to residents in care.

Official plan of correction

The Licensee will send notification to LPA Spaeth via email that the staff member was associated to the facility

Deadline recorded: Jan 8, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87761(b)

Regulation authority

CCR

What the official deficiency says

87761 Penalties(b)…a immediate penalty of $100 …per day for a maximum of five (5) days shall be assessed if any individual required to be fingerprinted …has not obtained a California clearance or a criminal record exemption… This is evidenced by: The Licensee failed to ensure a staff member had obtained a California Clearance or a criminal record exemption. This poses an immediate health and safety risk to residents in care.

Official plan of correction

LPA Spaeth observed the staff member (S2) left the facility.

Deadline recorded: Dec 5, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87202(a)(2)

Regulation authority

CCR

What the official deficiency says

87202(a)(2) All facilities shall maintain a fire clearance approved by fire dept... Prior to accepting any of the following types of persons, licensee shall obtain an appropriate fire clearance approved by fire dept, (2) Bedridden persons. This requirement is not met as evidenced by The Licensee failed to follow Title 22 Regulations regarding approved fire clearance, by placing bedridden resident R1 to the room that had no bedridden fire clearance. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Administrator stated that R1 will be transferred to bedroom #5 by 9/26/2024 and will send a snapshot of the room change.

Deadline recorded: Sep 27, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(j)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (j) The licensee shall have an auditory device…to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by: Due to LPA's observations, the Licensee failed to ensure the auditory devices were working at the front door and exit doors in Rooms 2 and 5

Official plan of correction

The Administrator will ensure the auditory devices at the front door, Room 2 and Room 5 are properly working. The Administrator will notify LPA Spaeth when the devices are repaired.

Deadline recorded: Sep 26, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87632(a)(1)

Regulation authority

CCR

What the official deficiency says

87632 Hospice Care Waiver (a) In order to accept or retain terminally ill residents & permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice waiver …(1) Specification of the maximum number of terminally ill resident which the facility wants to have…. This is evidenced by: The facility has an approved hospice waiver for three residents. However, LPA observed there are four out of five residents who are on hospice.

Official plan of correction

Administrator stated they will send a hospice waiver increase to the Woodland Hills South office.

Deadline recorded: Sep 27, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(b)(8)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records (b) each resident’s record shall contain….(8) names, address, & telephone numbers of resident’s representative….. This is evidenced by: LPA Spaeth observed the five residents' files did not contain a completed LIC 605 I.D. & Emergency Information and LIC 613C Personal Rights documents

Official plan of correction

The Administrator stated they will obtain the completed/signed forms and forward copies to LPA Spaeth via email.

Deadline recorded: Sep 27, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observation during the tour of the facility, the licensee did not comply with the section cited above. The water temperature was tested in the resident's bathroom and was 126.6 degrees F which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/07/2024 Plan of Correction During LPA's visit, the water temperature to the water heater was reduced. At 2:00 pm, LPA tested the water temperature in the resident's bathroom & observed the water temperature was 110.00 degrees F.

Official classification

Type A

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Deficient Practice Statement Based upon LPA's observation, the licensee did not comply with the section cited above. The two caregivers working at the facility verbally confirmed they had not completed CPR and first aid training which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/16/2024 Plan of Correction The Licensee will forward proof the two caregivers have completed the required training and send written confirmation to LPA Spaeth via email.

Official classification

Type B

Official code

87412(c)(2)(D)

Regulation authority

CCR

What the official deficiency says

(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. (2) Documentation of staff training shall include: (D) Number of training hours per subject. 2. If the educational hours/units are obtained through an accredited educational institution, documentation shall include a copy of a transcript or official grade slip showing a passing mark. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observation the licensee did not comply with the section cited above. The two caregivers have not completed the required job training which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/16/2024 Plan of Correction The Licensee will forward proof the two caregivers have completed the required training and send written confirmation to LPA Spaeth via email.

Official classification

Type B

Official code

87412(c)(2)(D)

Regulation authority

CCR

What the official deficiency says

(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. (2) Documentation of staff training shall include: (D) Number of training hours per subject. 3. If the educational hours/units are obtained through continuing education, documentation shall include a transcript or official grade slip showing a passing mark, if applicable, or a Certificate of Completion. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observation the licensee did not comply with the section cited above. The two caregivers have not completed the required job training which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/16/2024 Plan of Correction The Licensee will forward proof the two caregivers have completed the required on the job training and send written confirmation to LPA Spaeth via email.

Official classification

Type B

Official code

1569.626(a)(2)

Regulation authority

HSC

What the official deficiency says

(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: (2) Eight hours of in-service training per year on the subject of serving residents with dementia. This training shall be developed in consultation with individuals or organizations with specific expertise in dementia care or by an outside source with expertise in dementia care. In formulating and providing this training, reference may be made to written materials and literature on dementia and the care and treatment of persons with dementia. This training requirement may be satisfied in one day or over a period of time. This training requirement may be provided at the facility or offsite and may include a combination of observation and practical application. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observation, the licensee did not comply with the section cited above. The two caregivers have not completed the above-referenced training which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/16/2024 Plan of Correction The licensee will send written proof the caregivers have completed the training. The Licensee will send the written proof to LPA Spaeth via email.

Official classification

Type B

Official code

1569.69(a)(4)(D)

Regulation authority

HSC

What the official deficiency says

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (4) The training shall cover all of the following areas: (D) An explanation of the basic rules and precautions of medication assistance. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observation, the licensee did not comply with the section cited above. The two caregivers have not completed the above-referenced training which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/16/2024 Plan of Correction The Licensee will forward proof the two caregivers have completed the required training and send written confirmation to LPA Spaeth via email.

Official classification

Type B

Official code

1569.69(a)(4)(E)

Regulation authority

HSC

What the official deficiency says

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (4) The training shall cover all of the following areas: (E) Information on medication forms and routes for medication taken by residents. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observation, the licensee did not comply with the section cited above. The two caregivers have not completed the above-referenced training which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/16/2024 Plan of Correction The Licensee will forward proof the two caregivers have completed the required training and send written confirmation to LPA Spaeth via email.

Official classification

Type B

Official code

1569.69(a)(4)(F)

Regulation authority

HSC

What the official deficiency says

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (4) The training shall cover all of the following areas: (F) A description of procedures for providing assistance with the self-administration of medications in and out of the facility, and information on the medication documentation system used in the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observation, the licensee did not comply with the section cited above. The two caregivers have not completed the above-referenced training which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/16/2024 Plan of Correction The Licensee will send written proof of the caregivers' completion of the above described training. The Licensee will send proof to LPA Spaeth via email.

Official classification

Type B

Official code

1569.69(a)(4)(G)

Regulation authority

HSC

What the official deficiency says

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (4) The training shall cover all of the following areas: (G) An explanation of guidelines for the proper storage, security, and documentation of centrally stored medications. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observation, the licensee did not comply with the section cited above. The two caregivers have not completed the above-referenced training which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/16/2024 Plan of Correction The Licensee will send written proof of the caregivers' completion of the above described training. The Licensee will send proof to LPA Spaeth via email.

Official classification

Type A

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements-General (c) All RCFE staff who assist residents with personal activities & annual training as specified in Health and Safety Code sections…(1)Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Deficient Practice Statement Based on the LPA's observations, the licensee did not comply with the section cited above. The two caregiers have not completed the CPR and first aid training which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/12/2024 Plan of Correction The Licensee will send a copy of the caregiver's certificate of completion of the CPR and first aid training via email to LPA Spaeth

Official classification

Type A

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements-General (f) All personnel shall be in good health…Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician …A report shall be made of each screening, signed by the examining physician… This requirement is not met as evidenced by: Deficient Practice Statement Based on the LPA's observation the licensee did not comply with the section cited above. The two caregivers have not completed the health screening including the chest x-ray or an intradermal test which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/13/2024 Plan of Correction The Licensee will send the completed health screening paperwork for the two caregives to LPA Spaeth via email.

Official classification

Type B

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

87458 Medical Assessment (a) Prior to a person’s acceptance as a resident, the licensee shall obtain and keep on file documentation of a medical assessment, signed by a physician, made within the last year….This requirement is not met as evidenced by: Based on LPA's file review, the licensee did not comply with the section cited above in two out of four resident files which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator will provide copies of R1's and R2's records via fax or email to LPA Melissa Spaeth

Deadline recorded: Jan 26, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87507(b)

Regulation authority

CCR

What the official deficiency says

87507 Admissions Agreements (b) Admissions agreements shall be signed and dated,…by the resident. This requirement is not met as evidenced by: Based on LPA's file review, the licensee did not comply with the section cited above in two out of four resident files.

Official plan of correction

Administrator will provide copies of R1's and R2's records via fax or email to LPA Melissa Spaeth

Deadline recorded: Jan 26, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's file review, the licensee did not comply with the section cited above in two out of four staff files which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/16/2023 Plan of Correction Administrator will provide copies of S2 and S3 records via fax or email to LPA Melissa Spaeth

Official classification

Type B

Official code

87506(b)(15)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's records review, the licensee did not comply with the section cited above in two out of four resident files which poses/poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/16/2023 Plan of Correction Administrator will provide copies of resident records via fax or email to LPA Melissa Spaeth

Official classification

Type B

Official code

87457(c)(1)

Regulation authority

CCR

What the official deficiency says

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462, Social Factors. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's resident records review, the licensee did not comply with the section cited above in five of the five residents' files which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/09/2023 Plan of Correction Administrator will complete the pre-appraisal assessment prior to a resident moving into the facility.

Official classification

Type B

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's record review, the licensee did not comply with the section cited above in two out of four residents' records which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/16/2023 Plan of Correction Administrator will send a copy of the records to LPA Spaeth via email or fax.

Official classification

Type B

Official code

87458(b)(1)

Regulation authority

CCR

What the official deficiency says

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA Spaeth's file review, the licensee did not comply with the section cited above in three of five residents' files which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/16/2023 Plan of Correction Administrator will fax or email the documenation to LPA Spaeth

Official classification

Type B

Official code

87507(l)

Regulation authority

CCR

What the official deficiency says

(l) The licensee shall attach a copy of applicable resident's rights specified by law or regulation to all admission agreements, and shall include information on the reporting of suspected or known elder and dependent abuse, as set forth in Health and Safety Code Section 1569.889. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA Spaeth's record review, the licensee did not comply with the section cited above in five of the five residents' records which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/16/2023 Plan of Correction Administrator will fax or email the documenation to LPA Spaeth

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

87705 (f)(2) Care of Persons with Dementia Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in in that three (3) bottles of chemicals and disposable needles were accessible under the kitchen sink that did not have a proper lock, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/09/2022 Plan of Correction The Licensee shall provide in house training to all staff reviewing the regulation section cited above, and provide signatures of all staff members that completed the training to the LPA by the POC due date.