Emvy Board and Care Facility

Based on interview and record review the licensee did not comply with the section cited above in 3 out of 4 counts as Resident #1(last appraiisal 2/20/24), Resident #2 (last appraisal 9/10/23)and Resident #3 (last appraisal 5/24/24 have not beein reappraised since the last noted date, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review and interview with the Administrator, the licensee did not comply with the section cited above per review of Resident #4 medications, it was noted that Resident #4 was prescribed Ambien as needed on 7/16/25 but it was being dispensed daily as a routine medication without a change order 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 as it was observed that Resident #4 has PRN Ambien and Acetaminophen and does not have a completed PRN Authorization by the physician on file. 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 as it was observed that Resident #4 who has PRN Ambien was given a daily dose from 7/16/25 and there is no documentation of the date it was dispensed, no doctor instructions, time it was dispensed and no results of the dose cocumented by the staff which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review and interview with the Administrator, the licensee did not comply with the section cited above in all 4 counts. Staff have not been provided with PPE training which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on interview and observation, the licensee did not comply with the section cited above as Resident #2 was observed with a oxygen concentrator for as needed use and 2 full tanks of oxygen was observed stored in the garage for a former resident 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 as there were not signs observed posted on the doors that there is oxygen in use at the facility 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 as it was observed that Resident #4 has been receiving hospice services since 4/22/25 and it has not been reported to the Department 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 as it was observed that there is no hospice care plan or the specific services that will be provided in Resident #4's Hospice file in 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 all 2 counts as no LIC308s were completed were not observed in staffs' files for the morning and night shift 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 as the facility sketch does not identify the meeting point 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 as per review of the Plan of Operations, there was no bedridden plan observed 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 as it was observed that the dining room table had only 4 dining chairs for use and 2 dining room chairs were stored in the garage. One of the dining room chairs stored in the garage was broken 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 per tour of the facility, it was observed that bedroom #2 and bedroom #3 do not have chairs and bedroom #2 does not have any dressers, 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 all counts as copies of CEUs and a current Administrator Certificate was requested and the Administrator could not provide evidence that they were recertified as an Administrator] 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 as one (1) resident was identified to be at risk if allowed access to personal hygiene items and personal hygiene items were observed unsecured throughout the facility which poses a potential health and safety risk to persons in care.

Based on record review, the licensee did not comply with the section cited above as one (1) staff member lacked the required 20 hour annual training 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 as two (2) of two (2) resident centrally stored medication record sheets were missing perscribed medications which poses a potential health and safety risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above as one (1) resident has full bed rails but does not have a physician's order for them which poses a potential personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above as one (1) resident who is diagnosed with dementia lacked a physician's report dated within the last year which poses a potential health risk to persons in care.

Based on observation, the licensee did not comply with the section cited above as an unsecured box cutter was observed in an unlocked closet which posed an immediate health and safety risk to persons in care.

Based on interview, the licensee did not comply with the section cited above per information provided by the Administrator that the facility has internet but does not have any computers, tablets, smart phone or any other devices available to dedicate for the residents' use. Only one resident has own computer which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on interview the licensee did not comply with the section cited above and does not have a policy in place to address how the facility will make a device accessible to the residents in care to have discussions of personal or confidential information which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on interview, the licensee did not comply with the section cited above as the facility does not have a policy in place as to how they will make the computer, tablet or other devices accessible among the residents in the facility during reasonable hours, 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 per review of the MAR logs reviewed. The Licensee is inconsistent about updating the MAR log when medications are dispensed. Per review of the August 2023 MAR log, medications dispensed from 8/24/23 through 8/31/23 were not updated. Also, MAR logs from March 22, 2022 through July 2023 were not maintained,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 per information provided by the Administrator, one resident has dementia and one is able to make own decision. However, the physician has not been contacted to make a final decision if either resident is or is not able to make their own decision which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review and interviews, the licensee did not comply with the secction cited above per information provided, the facility does not document any dates of contact made with the physician, does not document the physician's instructions, the date the PRN's were dispensed, the dosage or the results of the dosage, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on interview, the licensee did not comply with the section cited above since the Administrator has not established with the prescribing physician if Resident #5 is able to make own decision to request the medications other than the licensee's own observation which poses an immediate health, safety or personal rights risk to persons in care.

Based on file review, the facility does not have any physician's order on file for any of the centrally stored medications 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 per review of medications, HumulinN prescribed for Resident #4 was stored on the refrigerator door in a zip lock bag 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 per review of all 5 resident files reviewed. Resident #1 through Resident #4 have not had a annual reappraisal review since as far back as 2013 and 2018, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPAs observation, the licensee did not comply with the section cited above as resident restrooms were observed not clean, or sanitary around the sink areas, which poses a potential health and safety risk to residents in care.