Heavenly Castle Care Inc

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Licensee does not have a statement signed by R2's roommate agreeing to share a room with R2 who is on hospice, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in R3 pill count being 1 pill off in two of R3's prescribed medications, which poses an immediate health, safety or personal rights risk to persons in care.

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in water measuring at 96.2 F in residents bathroom, which poses an immediate health, safety or personal rights risk to persons in care.

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Licensee not having training for staff for hospice care for R1, R2 and R3, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in R1, R2 and R3 not having a Hospice Care plan which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Licensee does not have any documentation in Hospice binders for residents on hospice, which poses/posed a potential health, safety or personal rights risk to persons in care.

87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, 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 observation, interviews, and records reviewed the licensee failed to log centrally stored medication indicated medication started on Monday 4/4/24 and after the count indicated the start date was 3/6/24. There was no verifiable date the medication started and the count of R3's Oxycodone was incorrect.

87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.This requirement is not met as evidenced by: Based on observation, interviews, and records reviewed the licensee failed to properly log R3's narcotic medication Oxycodone.This poses an immediate health, safety, or personal rights risk to residents in care.

87506 Resident Records(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.This requirement is not met as evidenced by: Based on observation, interviews, and records reviewed the licensee failed to provide resident records when LPA’s requested. Staff was asked for resident files to review and told LPAs to wait for the administrator.This poses a potential health, safety, or personal rights risk to the residents in care.

87608 Postural Supports(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.This requirement is not met as evidenced by: Based on observation, interviews, and records reviewed the licensee failed to obtain proper documentation for R1 to have full bed rails on the bed.This poses an immediate health, safety, or personal rights risk to residents in care.

Personnel Requirements - General87411 (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents. This requirement was not met as evidenced by Licensee did not ensure staff is able to communicate with LPA or residents which poses a potential health safety and or personal rights risk to residents in care.

87507 Admission Agreements (g) Admission agreements shall specify the following: (3) Payment provisions, including the following: (B) Rate for additional items and services, including 1. A comprehensive description of and the corresponding fee schedule for all additional items and services not included in the fees for basic services shall be listed. This requirement was not met as evidenced by: Licensee provided a service without completed receipts or a signed agreement between Licensee and resident which poses a potential health safety and or personal rights risk to residents in care.

Based on record review, the licensee did not comply with the section cited above in R1's PRN was not logged date or time which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in not having a written order from a physican on a prescription blank for all residents in care, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on interview and record review, the licensee did not comply with the section cited above in not having a hospice care plan for R2 and R3 which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above in Staff Arusyak Ayvazyan not being fingerprint cleared prior to working in the facility, which poses an immediate health, safety or personal rights risk to persons in care.

Based on interview and record review, the licensee did not comply with the section cited above in R1 ran out of PRN medications and medications were not refilled, which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in not having health screenings for staff, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in R1 running out of medications 7 days before the medications should have run out, which poses an immediate health, safety or personal rights risk to persons in care.

87705 (e) Care of Persons with Dementia: Swimming pools and other bodies of water shall be fenced and in compliance with state and local building codes. LPA observed an unfence pond on the premise of the facility.