IN R GREAT HANDS - MONTEVIDEO

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 observation and interview, the licensee did not comply with the section cited above in two of three staff files which poses a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/02/2026 Plan of Correction AAD stated staff files are maintained and will be available upon request. Per AAD, a copy of staff files will provided to LPA via email by POC date.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Deficient Practice Statement Based on staff interview and record review, the licensee did not comply with the section cited above in one of one staff files reviewed, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/02/2026 Plan of Correction AAD stated staff training will be completed and copy provided to LPA via email by POC date.

Official classification

Type B

Official code

1569.69(a)(2)

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: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. This requirement is not met as evidenced by: Deficient Practice Statement Based on staff interview and record review, the licensee did not comply with the section cited above in one of one staff files reviewed, which poses/posed a potential health, safety and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/02/2026 Plan of Correction AAD stated staff training will be completed and a copy provided to LPA via email

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 observation, the licensee did not comply with the section cited above in which the hot water temperature in the bathrooms were measured at 168 degrees F which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 12/10/2024 Plan of Correction Licensee shall ensure the hot water temperature is measured within the required range of 105-120 degrees F. Licensee shall submit the hot water temperature log to LPA by 12/10/24.

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). 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 that knives are placed in the dishwasher which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 12/10/2024 Plan of Correction Licensee shalll ensure all sharps are locked and inaccessible to residents. Licensee shall find a place to store the knives and submit the POC to LPA by 12/10/24.

Official classification

Type A

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidence by: During the course of complaint investigation, facility was unable to provide any documentation pertaining to R1, which poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

Licensee and Administrator will submit a statement that they have read and will be in compliance with regulation to LPA via email by POC date.

Deadline recorded: Mar 1, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(e)

Regulation authority

CCR

What the official deficiency says

Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement is not met as evidence by: During the course of complaint investigation, facility was unable to provide any documentation pertaining to R1, which poses a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

Licensee and Administrator will submit a statement that they have read and will be in compliance with regulation to LPA via email by POC date.

Deadline recorded: Apr 1, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

Additional Personal Rights of Residents in Privately Operated Facilities- Residents in privately operated residential care facilities for the elderly shall have the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers,qualifications and competency to met and competency to meet their needs. This requirement was not met as evidenced by Staff #1 told R1 to go in his diaper when he needed to use the bathroom. R1 developed a UTI.

Official plan of correction

Licensee agrees to train staff on the personal rights of residents and ensure that staff assist residents with services that meet their individual needs. Proof of training for staff will be provided via certification by 2/8/23.

Deadline recorded: Feb 8, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87625(b)(1)

Regulation authority

CCR

What the official deficiency says

Managed Incontinence- the licensee shall be responsible for the following: Ensuring that residents who can benefit from scheduled toileting are assisted or reminded to go to the bathroom at regular intervals rather than being diapered. This requirement was not met as evidenced by: Interviews disclosed that Staff #1 double diapered R1 instead of assisting R1 to the bathroom at regular intervals because " he wouldn't make it. "

Official plan of correction

Licensee agrees to review Section 87624 Managed Incontinence and ensure that procedures are put into place for incontinent residents upon admission. Certification will be provided of review and understanding by 2/8/23.

Deadline recorded: Feb 1, 2023. A deadline is not proof that correction was completed.