WHOLESOME ELDERLY ON KIFISIA

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observations and records reviewed, the facility did not ensure that one (1) resident had all medications documented on site, and did not ensure that documentation on Medication Administration Record (MAR) was accurate, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/23/2025 Plan of Correction Facility will obtain updated information regarding resident's medications and submit information to LPA by POC due date. Facility will also complete an in-service training regarding medications with all care staff, including reporting missed medications and proper medication documenting. Facility will submit date of in-service training and training material to LPA by POC due date. A civil penalty in the amount of $250 is being assessed for today's date due to a repeat violation.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility (...) by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on medication review and records reviewed, the facility did not ensure that resident (R1) was receiving all medications prescribed as needed, which poses an immediate health, safety, and personal rights risk to residents in care.

Official plan of correction

Facility will create a plan regarding when a resident is out of the facility or medications are not on cite to ensure that residents are obtaining medications as needed. Facility will submit plan to LPA by POC due date. A civil penalty assessment in the amount of $250 was assessed for today's date for a repeat violation.

Deadline recorded: Jul 16, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care Services (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Based on LPA's observations, facility did not ensure that centrally stored medication was locked and inaccessible to the residents in care, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Facility locked unlocked medication storage during visit. Facility will complete a statement of understanding and submit statement to LPA by POC due date of 3/07/2025. A civil penalty in the amount of $250 was issued for a repeat violation.

Deadline recorded: Mar 7, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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. This requirement is not met as evidenced by: Based on LPA's observations, staff did not ensure facility was in good repair when kitchen sink was leaking, which poses a potential health, safety, and personal rights risk to residents in care.

Official plan of correction

Facility will hire services to fix kitchen sink. Facility will submit proof of services to LPA by POC due date. A civil penalty in the amount of $250 was issued for a repeat violation.

Deadline recorded: Mar 21, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care Services (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Based on LPA's observations, facility did not ensure that centrally stored medication was locked and inaccessible to the residents in care when key to medications was left in medication cabinet, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Facility locked unlocked medication storage during visit. Facility will complete an in-service training for staff regarding medications. Facility will submit date of training and training materials to LPA by POC due date of 1/08/2025. A civil penalty in the amount of $250 was issued for a repeat violation.

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

Official classification

Type B

Official code

87307(a)

Regulation authority

CCR

What the official deficiency says

87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. This requirement is not met as evidenced by: Based on LPA's observations, facility did not ensure that staff were not sleeping in an area designated for sleep when establishing a staff bedroom in a space designated as the garage, which poses a potential health, safety, and personal rights risk to residents in care.

Official plan of correction

Administrator will remove bedroom set up in garage by POC due date of 1/22/2025.

Deadline recorded: Jan 22, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87307(e)

Regulation authority

CCR

What the official deficiency says

(e) Facilities providing services to residents who have physical or mental disabilities shall assure the inaccessibility of fishponds, wading pools, hot tubs, swimming pools or similar bodies of water, when not in active use by residents, through fencing, covering or other means. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPAs' observations, facility did not ensure to keep pool on the premises locked and inaccessible to the residents in care, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/03/2024 Plan of Correction Facility placed lock on unlocked gate to pool during inspection. Facility will ensure that pool on the premises is locked at all times. Facility will complete a statement of understanding regarding regulation 87307 and submit statement to LPA by POC due date. An immediate civil penalty in the amount of $500 is assessed for a body of water being accessible to residents in care.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPAs' observations and records reviewed, the facility did not ensure to document start dates for medications administered, which poses an immediate health, safety or personal rights risk to persons in care. LPAs' also observed loose, unidentified medications in the residents' medication storage units.

Official plan of correction

POC Due Date: 10/03/2024 Plan of Correction Facility will use centrally stored medication (CSMF) form to document medications administered. Facility will submit completed CSMF for all residents to LPA by POC due date.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on on LPAs' observations, facility did not ensure to keep centrally stored medications locked and inaccessible to the residents in care, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/03/2024 Plan of Correction Facility locked unlocked medication storage during visit. Facility will ensure that centrally stored medication is locked and inaccessible to the residents in care at all times. Facility will complete a statement of understanding regarding regulation 87465 and submit statement to LPA by POC due date.

Official classification

Type B

Official code

87458(c)

Regulation authority

CCR

What the official deficiency says

87458 Medical Assessment (c) The licensee shall obtain an updated medical assessment when required by the Department. This requirement is not met as evidenced by: Deficient Practice Statement Based on records reviewed, LPAs observed that resident (R1) only had one (1) medical assessment for 6/3/2022 when they were placed on hospice and graduated from hospice following their last assessment, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/17/2024 Plan of Correction LPA is requesting that facility obtain a new medical assessment for R1 following a change in condition. Facility will submit completed current medical assessment for R1 to LPA by POC due date of 10/17/2024.

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 observations, the facility did not ensure that hot water temperatures were maintained not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C) when hot water was measured to be 123 degrees F, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/31/2023 Plan of Correction Facility will decrease hot water temperatures to be maintained not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C) by POC due date.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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. This requirement is not met as evidenced by: Deficient Practice Statement Based on observations, facility carpets were stained, trash compacter was in disrepair, gate in backyard was in disrepair, ice machine was in disrepair, and locks on drawers were in disrepair, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/30/2023 Plan of Correction Facility will repair carpets, repair or remove trash compacter, repair backyard gate, repair locks on drawers, and either repair ice machine or provide another method for the facility to have ice. Repairs will be completed by POC due date.

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

87203 Fire Safety - All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by: Deficient Practice Statement Based on observations, the facility did not ensure that fire extinguishers were serviced and carbon monoxide detectors were operational, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/31/2023 Plan of Correction Licensee will service fire extinguishers and install carbon monoxide detectors. Licensee will submit proof to LPA be POC due date. An immediate civil penalty in the amount of $500 was assessed.