Pathways

The facility failed to complete an initial assessment within 72 hours of admission using the Resident Register for Resident #2. A review of the resident's record revealed that no Resident Register was available for review, and staff were unable to confirm the resident's admission date.

The facility failed to ensure that Resident #2 was not admitted for the treatment of a mental illness, which is an exception to admission. The resident's record showed diagnoses of bipolar type and schizoaffective disorder, and the Administrator was unaware that residents with only mental health diagnoses could not be admitted.

The facility failed to ensure that a resident was not admitted for the treatment of a mental illness. Specifically, Resident #2 was admitted with diagnoses of bipolar type and schizoaffective disorder, and the Administrator was unaware that residents cannot be admitted solely for mental health diagnoses.

The facility failed to notify the Division of Health Service Regulation that a resident's evacuation capabilities had changed. Specifically, one resident with cognitive impairments was identified who could not independently evacuate, which differs from the facility's license for 6 ambulatory residents.

The facility failed to notify the Division of Health Service Regulation that a resident's evacuation capabilities had changed. Specifically, one resident with cognitive impairments was identified who could not independently evacuate, which differs from the facility's license for 6 ambulatory residents.

The facility failed to notify the Division of Health Service Regulation that a resident's evacuation capabilities had changed. One of four sampled residents had cognitive impairments that prevented independent evacuation, which differed from the facility's license for ambulatory residents.

The facility failed to ensure residents' evacuation capabilities were in accordance with the capabilities listed on the current license. Specifically, one resident with cognitive impairments required verbal prompting to exit the facility during a fire drill.

The facility failed to maintain clean and well-repaired walls, ceilings, and floors. Specific deficiencies included dirty baseboards with dust, scraped paint on walls, peeling paint on ceilings, and cobwebs in resident rooms and the common bathroom. Additionally, there were visible stains on the shower grout and closet doors.

The facility failed to maintain clean and well-repaired walls, ceilings, and floors. Specifically, dirty baseboards, scraped paint, and cobwebs were observed in multiple resident rooms, and staff failed to ensure regular cleaning and repair reporting.

The facility failed to meet minimum lighting requirements in one of two resident bathrooms. Specifically, the light fixture in bathroom #2 was non-functional due to a burnt-out bulb that had not been replaced for approximately one month. The supervisor noted that the maintenance person had not addressed the issue because the fixture was too high and other repairs were prioritized.