Family Courtyard

Based on observation, the licensee did not comply with the section cited above in having ambient air temperature in hallways measuring 61 degrees Fahrenheit and LPA and LPM observed that the physical plant was cold; LPM also observed 2 residents stating that they were cold; which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in not having window covers on Room 35 which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in not having adequate lighting throughout hallways. which poses a potential health, safety or personal rights risk to persons in care.

87415 Night Supervision (a)...from l0:00 p.m. to 6:00 a.m. shall be familiar with the facility's planned emergency procedures, shall be trained in first aid as required...(2 )In facilities caring for sixteen (16) to one hundred (100) residents at least one employee shall be on duty on the premises, and awake. Another employee shall be on call, and capable of responding within ten minutes. - This requirement was not met as evidenced by:Based on records reviewed, Licensee did maintain the staff schedule to cover all shifts with contact information for on-call staff which poses/posed a potential health and safety risk to residents in care.

(e) Faucets used by clients... shall deliver hot water.(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water... a hot water temperature of not less than 105 degrees F and not more than 120 degrees F Based on observation, the licensee did not comply with the section cited above by having hot water temperature at 94.6 which poses an immediate health and safety risk to persons in care.

87303 Maintenance and Operation.(a) The facility shall be clean...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. LPAs observed two bicycles in disrepairin the gazebo area, trash in the gazebo area, various construction tools such as a bucket, 2 by 4s, caulking tubes, a puddy knife, ect., multiple areas with debris/tras, three paint cans on the table outside of the dining area, most bathrooms missing toilet paper and hand soup and two out of service.

87303 Maintenance and Operation.(d) There shall be lamps or light appropriate for the use of each room and sufficient to ensure the comfort and safety of all persons in the facility. LPAs observed facility to not have adequate lighting throughout hallways.

87303 Maintenance and Operation.(c) All window screens shall be clean and maintained in good repair. LPAs observed multiple windows with missing or broken screens.

87555 General Food Service Requirements (b) The following food service requirements ...for sixteen (16) persons or more, menus shall be written at least one week in advance and copies of the menus as served shall be dated and kept on file for at least 30 days.-This requirement was not met as evidenced by: Based on observations and interviews, weekly menuswere not posted and kept on file per the regulation which poses/posed a potential health and safety risk to residents in care.

87507 Admission Agreements (g)... shall specify the following: (4) Modification conditions...at least 60 days prior written notice to the resident of any rate or rate structure change, or as soon as the licensee is notified of SSI/SSP rate changes.-This requirement was not met as evidenced by: Based on records reviewed and interviews, Licensee/ADM did not provide residences proper notice of rate increases per the regulations.

87309 Storage Space and Access(a) ...ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger...are not left unattended if outside the locked storage. Based on observations and interviews, S5 left cleaning solutions unattended which posed an immediate health and safety risk to residents in care.

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. Based on records reviewed, Licensee did maintain clean, safe and sanitary conditions which poses/posed a potential health and safety risk to residents in care.

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (2) Occurrences, such as epidemic outbreaks,poisonings, catastrophes or major accidents which... threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. -This requirement is not met as evidenced by: ADM/Licensee did not report R1's 51/50 hold to CCLD within 24 hrs.

87506 Resident Records (b) Each resident’s record shall contain at least the following information:-This requirement is not met as evidenced by: -Based on recrords reviwed, the ADM/Licensee did not maintain R1's records which poses/posed a potential health and safety risk to persons in care.

87412 Personnel Records (c) Licensees shall maintain in the personnel records verification of records (1) training and orientation shall be documented: (A) For staff who assist with personal activities of daily living …at least ten hours of initial training within the first four weeks of employment, and at least four hours of training annually …areas as specified in Section 87411(c)(2). - This requirement was not met as evidenced by: Based on records reviewed, Licensee did maintain annual training records for S1 which posed a potential health and safety risk to residents in care.

Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by not administering medications according to physician's order which poses an immediate health and safety risk to the persons in care.

Based on observation and record review the licensee did not comply with the section cited above by having a matress, wooden boards, metal items, and white PVC tubing in the backyard which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, interviews, and record review the licensee did not comply with the section cited above in 3 out of 3 gates having padlocks attached which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, interviews and record review, the licensee did not comply with the section cited above by not providing hot water at a least 105 F., keeping facility free of mildew, and keeping residents' room in sanitary condition which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in having key padlocks on the exit gate and drive gate on right side of building locked which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in have facility's window, ceiling and heater in repair which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in having passageway free of obstruction which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in having a complete first aid kit which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in having 7-day perishable and 2-day non perishable foods for residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Incidental Medical and Dental Care. The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained... This requirement is not met as evidence by: Based on record review, licensee did not comply with the section cited above by not having centrally stored records for a few residents which poses a potential health and safety risk to the persons in care.

Based on observations and interviews, the licensee did not comply with the section cited above. LPAs observed a broken grab bar in the bath room of room #32 which poses a potential health and safety risk to persons in care.

Based on observations and interviews, the licensee did not comply with the section cited above. LPA's observed closet door and blinds of bedroom #32 and vanity cabinet door and blinds of bedroom #23 in disrepair which poses a potential health and safety risks to persons in care.

Based on observations and interviews, the licensee did not comply with the section cited above. LPA's observed mold/mildew in shower room #1 and #2, and the shared sink area at rooms #14, #15, and room #17 had cobwebs around the sink which poses potential risks to persons in care.

Based on observations and interviews, the licensee did not comply with the section cited above. LPA's observed hot water tempertaure in shower room #2 at 68.6 degree F and 93.4 degree F in the shared common bathroom.

87463 Reappraisals (a)The pre-admission appraisal shall be updated, in writing to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes physical, medical, mental, and social condition. -This requirement is not met as evidenced by: -Based on interviews and record reviews, the Administrator did not comply with the section above by not updating R1's Weight Records, LIC601, LIC603, LIC613C and Consent for Emergency Care which poses a potential health and safety risk to persons in care.