| Facility failed to meet the following Requirement(s): | Corrected Date | Level of Harm | Residents Affected |
| General Requirements.
(A) If the facility admits or retains any individual needing more than minimal assistance due to having a physical, cognitive or other impairment that prevents the individual from safely evacuating the facility, the facility shall:
6. At a minimum the evacuation plan shall include the following components:
A. The responsibilities of specific staff positions in an emergency specific to the individual; II
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6/10/2024
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| General Requirements.
(A) If the facility admits or retains any individual needing more than minimal assistance due to having a physical, cognitive or other impairment that prevents the individual from safely evacuating the facility, the facility shall:
6. At a minimum the evacuation plan shall include the following components:
C. The plan shall evaluate the resident for his or her location within the facility and the proximity to exits and areas of refuge. The plan shall evaluate the resident, as applicable, for his or her risk of resistance, mobility, the need for additional staff support, consciousness, response to instructions, response to alarms, and fire drills; II
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6/10/2024
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| The facility shall screen residents and staff for tuberculosis as required for long-term care facilities by 19 CSR 20-20.100. II
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6/10/2024
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| The administrator shall maintain on the premises an individual personnel record on each facility employee, which shall include the following:
(I) Written statement signed by a licensed physician or physician ' s designee indicating the person can work in a long-term care facility and indicating any limitations; III
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6/10/2024
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| The facility may admit or retain an individual for residency in an assisted living facility only if the individual does not require hospitalization or skilled nursing placement as defined in this rule, and only if the facility:
(F) Completes a community based assessment conducted by an appropriately trained and qualified individual as defined in section (4) of this rule:
1. Time frame requirements for assessment shall be:
A. Within five (5) calendar days of admission; II
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6/10/2024
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| Residents shall receive proper care as defined in the individualized service plan. I/II
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6/10/2024
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| Staffing Requirements.
(A) The facility shall have an adequate number and type of personnel for the proper care of residents, the residents ' social well being, protective oversight of residents and upkeep of the facility. At a minimum, the staffing pattern for fire safety and care of residents shall be one (1) staff person for every fifteen (15) residents or major fraction of fifteen (15) during the day shift, one (1) person for every twenty (20) residents or major fraction of twenty (20) during the evening shift and one (1) person for every twenty-five (25) residents or major fraction of twenty-five (25) during the night shift. I/II
Time Personnel Residents
7 a.m. to 3 p.m.
(Day)* 1 3-15
3 p.m. to 9 p.m.
(Evening)* 1 3-20
9 p.m. to 7 a.m.
(Night)* 1 3-25
*If the shift hours vary from those indicated, the hours of the shifts shall show on the work schedules of the facility and shall not be less than six (6) hours. III
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6/10/2024
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| The facility shall develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of any resident and misappropriation of resident property and funds, and develop and implement policies that require a report to be made to the department for any resident or to both the department and the Department of Mental Health for any vulnerable person whom the administrator or employee has reasonable cause to believe has been abused or neglected. II/III
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6/10/2024
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| Each resident shall be treated with consideration, respect, and full recognition of his or her dignity and individuality, including privacy in treatment and care of his or her personal needs. All persons, other than the attending physician, the facility personnel necessary for any treatment or personal care, or the department or Department of Mental Health staff, as appropriate, shall be excluded from observing the resident during any time of examination, treatment, or care unless consent has been given by the resident. II/III
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6/10/2024
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| Each resident shall be permitted to retain and use personal clothing and possessions as space permits. Personal possessions may include furniture and decorations in accordance with the facility's policies and shall not create a fire hazard. The facility shall maintain a record of any personal items accompanying the resident upon admission to the facility, or which are brought to the resident during his or her stay in the facility, which are to be returned to the resident or responsible party upon discharge, transfer, or death. II/III
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6/10/2024
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