Four Diamonds

Based on observation, the licensee did not comply with the section above; resident (R6's) Tamsulosin .4mg & Tylenol have not been 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 that R3's Physician's Report is dated 1/17/2024, R4's Physician's Report is dated 8/30/2024, R5's Physician Report is dated 5/10/2023 & R6's Physician's Report is dated 2/5/2024, which poses 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 that proof of staff training was not available for review, which poses 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 because resident's R1, R2, & R3 do not have Pre-Admission Appraisals on file, which poses 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 that R1's Medical Assessment dated 9/29/2025 is missing TB exam/ results, which poses 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 that residents (R1- R5) are missing file documents i.e., Pre-Admission Appraisal, ID and Emergency Information, Safeguards for property/valuables, 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 that the front door has a slip latch lock on the top of the door above the auditory alarm that was turned off, as well as a locking mechanism latch by the door handle, which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review, all resident admission agreements have an Addendum that was not approved by CCL that states the refund policy as "No refund shall be given ...any and all payments made are considered monthly and never daily", which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, resident room #3 has a toilet leak and walls are in disrepair, which poses 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 that Administrator certificate expired 4/23/2024 and recertification documents were sent until 9/3/24,which poses 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 that all resident files did not have pre-admission appraisals, only R5 has a resident appraisal, which poses a potential health, safety or personal rights risk to persons in care.

Based on record review, the facility is using and ARF Physician's Report form for R1 instead of an RCFE form and hospice resident (R4's) file is missing MD report and needs and services plan, which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, licensee has 3 oxygen tanks that are no longer being used in the garage, 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 that the kitchen sink water temperature was 126.7 DF, 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 that R1's Quetiapine Fumarate 25 mg is a PRN med, but is being given as a routine noon medication, and the physician order for Vitamin C is 500 mg, but 1000 mg is being given, 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 above in that R1 OTC Calcium 1200 mg, B-12 (5000 mg), and Vitamin K do not have a physician order and it is not documented on Centrally Stored Records, 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 that Staff (S2's) medications pills and R3's Cholestyramine Light Powder were unlocked in a kitchen cabinet, and R2's Betamethasone Dipropionate Lotion & Hydrocortizone Cream were unlocked in the living room recliner, 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 that residents (R1, R2, & R4) have full bed rails without a physician order. R1 is receiving palliative care and R2 & R4 are not enrolled in hospice care, which poses an immediate 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 that LIC 610D Emergency Disaster Plan was not posted, which poses/posed a potential health, safety or personal rights risk to persons in care.

87412 Personnel Records(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.This requirement was not met as evidenced by: Based on interviews, observations, and records review, it was determined the licensee failed to maintain personnel records verification of required staff training and updated COVID-19 training for all staff currently employed.

87470 Infection Control Requirements(c) An Infection Control Plan shall be developed by the licensee...(1) The Infection Control Plan shall include all of the following:(C)An Infection Control Training Plan. (3.)The description of initial and ongoing training...This requirement was not met as evidenced by: Based on interviews, observations, and records, review, it was determined that the licensee who is also the infection preventionist has failed to provide ongoing training to staff regarding infection prevention of communicable diseases, including COVID-19.

Criminal Record Clearance. A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility by providing the following documents to the Department.A signed Criminal Background Clearance Transfer Request, LIC 9182 (Rev. 4/02).This requirement is not met as evidenced by: Based on records reviews Staff (S3) is not associated to the facility. S1 began working at the facility yesterday June 14, 2022.This poses an immediate health and safety risk to residents in care.

87705(f)(1) Care of Persons with Dementia. The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).This poses and immediate health and safety risk to residents in care. Based on observation 2 knives were observed on top of the counter, 1 on the dish rack, and the sharps/knives drawer was unlocked. Pictures were taken.This poses an immediate health and safety risk to residents in care.