Tcal 2 LLC

A relicensure survey was completed on 7/17/24. Deficiencies were cited. Based on interview and record review, the residence failed to develop written policies and procedures regarding visitation affecting 10 current residents.Findings include:The residence' s undated Visitor Policy read in part: Visitors must sign in, be screened and wear PPE, wash hands, and minimize contact with others and discard PPE outside.However, the residence' s policy failed to contain the following elements: The policy was required to include part (F) (4)(A-B) Require visitors to sign a document acknowledging: (a) (b) The risks of entering the residence while the risk of transmission of a communicable disease is heightened; and That menacing and physical assaults on health-.. Based on interview and record review, the residence failed to develop written policies and procedures regarding visitation affecting 10 current residents.Findings include:The residence' s undated Visitor Policy read in part: Visitors must sign in, be screened and wear PPE, wash hands, and minimize contact with others and discard PPE outside.However, the residence' s policy failed to contain the following elements: The right of each resident of an assisted living residence to have at least one visitor of the resident' s choosing during their stay at the residence, unless restrictions or limitations under federal law or regulation, other state statute, or state or local public health order a.. Based on interview and record review, the residence failed to ensure they had defined procedures to prevent the spread of influenza from unvaccinated healthcare workers affecting 10 current residents.Findings include:The residence' s undated Vaccination Policy read in part: Any staff that was not able to take the vaccine must take extra precautions when working around non-vaccinated staff or residents. However, the policy failed to include defined procedures for preventing the spread of influenza from unvaccinated healthcare workers.On 7/17/24 at 2:00 p.m., Staff #2 stated she was unaware the residence was required to include the specific procedures taken by unvaccinate.. Based on observation and interview the residence failed to ensure the administrator completed the additional 10 hours of training as required affecting 10 current residents.Findings include:During an environmental tour on 7/17/24 at 9:16 a.m., the wall at the main entrance had a posting of the administrator training course. The training certificate read the administrator had completed the 30 hour course. A second posting located on the wall at the main entrance read the administrator had completed a training course for alternative care facilities through the department. On 7/17/24 at 9:24 a.m., Staff #2 stated she was not aware of the required 40 hour administrator training and stated she would .. Based on observation, record review, and interview, the residence failed to maintain the residence' s water temperature, that was accessible by residents, at or below 120 degrees Fahrenheit (F) at taps, affecting 10 current residents.Findings include:On 7/17/24 at 11:30 a.m., water temperatures were taken in the residence as follows:The common area kitchen sink measured 158 degrees F.The common area bathroom sink #1 measured 160 degrees F.The common area bathroom sink #2 measured 157 degrees F.On 7/17/24 at 12:59 p.m., Staff #2 stated they were unaware of the regulation and that they did not regularly monitor the water temperature. Staff #2 stated water that measure..

A recertification survey was completed on 7/17/24. A deficiency was cited. Based on observation, interview, and record review, the residence failed to follow written procedures for the administration of medication in accordance with Chapter VII affecting two of three sample residents (#1 and #3). Findings include:1. Residence PolicyThe residence' s policy titled Goods and Services Provided to Residents, dated 2018, read in part: "Medications for residents would be monitored per practitioner' s orders and can be delivered by the pharmacy of choice." "Health and medication records would be kept from all residents."a. Chapter VII regulations governing assisted living residences, requires in part 14.21 that the assisted living residence shall be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers. Resident #1 was admitted to the residence on 4/7/22.An authorized practitioner' s order, dated 3/13/24, directing the residence to administer vitamin D3 (cholecalciferol) 1.25 mg one time weekly. However, the June and July 2024 medication administration records (MARs) read vitamin D2 1.25 was administered on 6/2, 6/9, 6/16, 6/23, 6/30, 7/7, and 7/14/24. A medication cart audit revealed the residence did not have the prescribed vitamin D3 in stock. However, the medication cart did contain vitamin D2.On 7/17/24 at 1:30 p.m., Staff #2 stated that the practitioner was working on transferring medication orders to the pharmacy due to billing issues and understood that the practitioner' s orders did not match the MARs or the medication that the staff administered.b. Chapter VII regulations governing assisted living residences, requires in part 14.33 that the assisted living residence shall ensure that the resident' s authorized practitioner and resident' s legal representative are promptly notified of a resident' s repetitive request for and use of PRN medication. Resident #3 was admitted to the residence on 10/10/16 with a diagnosis consisting of chronic back pain.An authorized practitioner' s order, dated 7/30/22, directed the resid..

A revisit survey was completed on 6/15/23 for all previous deficiencies cited on 5/5/22. No deficiencies were cited. Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally