Annabelle's Cottage

Based on LPA's observation, the licensee did not comply with the section cited above. The water temperature was 126 Degrees F which poses a potential health, safety or personal rights risk to persons in care.

Based on LPA's observations, the licensee did not comply with the section cited above. Two out of three resident's medications did not contain a pharmacy prescription label which poses a potential health, safety or personal rights risk to persons in care.

87457 (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs…This requirement is not met as evidenced by: The Administrator failed to complete an Admissions Appraisal prior to the resident moving into the facility, which poses an immediate health, safety or personal rights risk to persons in care.

87507 Admissions Agreement (a) The licensee shall complete an individual written admission agreement. This requirement is not met as evidenced by: The Administrator failed to obtain a signed Admissions Agreement which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPA Spaeth's entrance to the facility, LPA observed a relative of the caregiver who has not obtained a criminal record clearance. The licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA Spaeth obseved the relative left the facility at 11:15 am.

Based on LPA's review of staff records, the licensee did not comply with the section cited above. Based upon LPA's review of Staff (S1) records, the staff member has not completed the CPR/first aide training which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPA's observations, the knives and the gardening tools were not safely locked. The licensee did not comply with the section cited above in two out of two incidents which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPA's observations, the licensee did not comply with the section cited above. The egress system was not properly working which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPA's observations, the licensee did not comply with the section cited above. The medication cabinet was not locked which poses an immediate health, safety or personal rights risk to persons in care.

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives…tools and other items that could constitute a danger to the resident(s).This requirement is not met as evidenced by: Based on LPA's observations, a four-prong grilling utensil was beside the outdoor grill, was not locked & the laundry room was not locked & contained laundry soap & cleaning solutions. This poses an immediate health & safety risk to the residents in care.

Based on LPA Spaeth observations, the staff records were not available to LPA, the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPA Spaeth observations, the licensee did not comply with the section cited above in one out of five staff members which poses an immediate health, safety or personal rights risk to persons in care.

Personal Rights (a) Residents in residential care facilities for the elderly shall have personal rights...(2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This was evidenced by: The resident wandered away from the facility at about 10:30 am on 4/01/2022 and brought back to the facilty by a neighbor. Also, based upon LPA interviewing the caregiver, the resident to leave the facility without supervision which is an immediate health and safety risk to residents in care.

87705Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia:(1) Knives...(2) Over-the-counter medication, cleaning supplies and disinfectants.This requirement is not met as evidenced by: Based on observation, the licensee failed to ensure cleaning supplies (toxins) were inaccessible to dementia residents which poses an immediate health risk to residents in care.

1569.696(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care...the training requirements specified in .... The training shall include all of the following: This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above by not ensuring staff received the required training which poses a potential health, safety or personal rights risk to persons in care.

Fire Clearance Violations, including, but not limited to, over capacity, ambulatory status, inoperable smoke alarms, and inoperable fire alarm systems. All facilities shall secure and maintain a fire clearance approved by the city or county fire department, This is not met as evidenced by observation and inteview the licensee did not comply with the regulation above by not ensuring the smoke detectors are operational which poses an immediate health,safety personal rights risk to persons in care.

87205 (b) Accountability of Licensee Governing Body-(b) If the licensee is a corporation or an association, the governing body shall be active, and functioning in order to assure accountability. This requirement is not met as evidenced by: the licensee did not comply with the section cited above by not ensuring that the corporation remains active which poses a potential health, safety and personal rights risk to persons incare.

False Claims: No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement is not met as evidenced by: Based on interview, the licensee did not comply with the section cited above by providingfalse/misleading statement regarding the designated facility administrator.

87305(a) Alterations to Existing Building or New Facilities Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by: Based on observations, the licensee did not comply with the section cited above by building unpermitted staff rooms in the garage which poses an immediate health, safety and personal rights risk to persons in care and staff.

87405(a) All facilities shall have a qualified and currently certified administrator. This requirement is not met as evidenced by: Based on observation, interview and record review, the licensee did not comply with the section cited above by not having a certified administrator working which poses a potential health, safety, personal rights risk to persons in care.

87411(c)(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above by not ensuring 5 out of 8 staff received first aid training which poses a potential health, safety or personal rights risk to persons in care.

87411(d)(5) (d) All personnel shall be given training... This training ...shall provide knowledge of and skill in the following,.. for the job assigned and ... job performance: (5) Knowledge necessary in order to recognize early signs of illness and the need for professional help. This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above by not providing staff training on infection prevention, symptoms, transmission and PPE use by any individual trained in infection control which poses an immediate health, safety or personal rights risk to persons in care.

87411 (f) Personnel Requirements - General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by. Based on interview, the licensee did not comply with the section cited above by not having qualified staff on the premises at nights resulting in absence of supervision for the 2 residents in care which poses an immediate health, safety personal rights risk to persons in care.

Licensee is required to have PRN authorization letter on file signed by a physician to determine whether or not the residents can communicate the need and/or symptoms clearly for the as needed (PRN) medication. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above by notobtaining PRN authorization letters for 2 residents which poses a potential health,safety or personal rights risk to persons in care.

87465 (h)(6) (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications ... is maintained for at least one year and includes… This requirement is not met as evidenced by:Based on interview and record review, the licensee did not comply with the section cited above by not completing/retaining centrally stored medication & destruction record for 2 out of 2 residents which poses a potential health, safety and personal rights risk to persons in care

Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on observation the licensee did not comply with the section cited above by not conducting routine symptom screening for resident,staff & visitors which poses an immediate health, safety, personal rights risk to persons in care.

Residents in all residential care facilities shall have all of thefollowing personal rights: (1)To be accorded dignity in their personal relationships with staff. This requirement was not met as evidenced by: Based on observation, interview, the licensee did not comply with the section by R1 by placing a baby monitor in resident room to monitor residents at night which poses an immediate health, safety and personal rights risk to persons in care.

87608 Postural Supports (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record... This requirement was not met as evidenced by: LPA reviewed resident file and did not find a written order for the resident's half bed rails.

87608 Postural Supports (a)(5)(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently on hospice care and..hospice care plan that specifies the need for full bed rails.This requirement was not met as evidenced by: Licensee did not comply with the section cited above by utilizing full bedrails for R1 who is on hospice however licensee does not have hospice care plan which indicates the need which poses an immediate health, safety personal rights risk to R1.

In order accept or retain terminally ill residents &... receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department. This requirement was not met as evidenced by: Based on record review,the licensee did not comply with the section cited above by retaining 2 residents on hospice prior to obtaining an approved hospice waiver which poses an potential health, safety & personal rights risk to persons in care.

87633(b) A current and complete hospice care plan shall be maintained ... for each hospice resident and include the following: This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above by not obtaining hospice plans for R1 and R2.

87705 Care of Persons with Dimentia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement was not met as evidenced by: Based upon LPA's observations, the alarm on all exit doors were not working. This poses an immediate health, safety and personal rights risk to persons in care.

1569.311 Carbon monoxide detectors required; inspection. Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility...This requirement is not met as evidenced by: Based on observation and interviews, licensee failed to ensure the facility had one or more carbon monoxide detectors at the facility which poses an immediate health and safety risk to residents in care.

87555(b) General Food Service Requirements (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement was not met as evidenced by: Based upon LPA's observation the facility did not have an adequate supply of fresh fruits and vegetables and canned goods.

1569.625(b) Staff training; legislative findings; contents. (1) The department ...staff members ...who assist residents with personal activities of daily living to receive ... training. This training shall consist of 40 hours of training. ...(2) training requirements shall also include an additional 20 hours annually…. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above by not ensuring staff received the required training which poses a potential health, safety or personal rights risk to persons in care.

Liability insurance; coverage requirements On and after July 1, 2015, all residential care facilities for the elderly...shall maintain liability insurance covering injury to residents and guests...This requirement was not met as evidenced by: Based on interview, the licensee did not comply with the section cited above as the failing to obtain/maintain liability insurance which poses a potential health, safety, personal rights risk to persons in care.

1569.69(a) Each residential care facility...shall ensure ... employee ... who assists residents with the self-administration of medications meets... training requirements: This requirement is not met as evidenced by: Upon review of the staff records, LPA observed staff has not completed the required medication trainnig.