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Based on observation, and interview, the licensee did not comply with the section cited above. Resident medications observed pre-set for 7-days. This poses an immediate health, and safety risk to persons in care.

Based on observation, interview, record review, the licensee did not comply with the section cited above. Full rail observed on resident #5's bed; resident is not on hospice at this time. This poses an immediate health,safety and personal rights risk to persons in care.

Based on observation, interview and record review, the licensee did not comply with the section cited above. Five out five resident centrally stored medication records were reviewed with administrator. Administrator confirmed that the records are not updated accordingly. This 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. (2) main caregivers did not have proof of required training on file. This 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. Staff #2 assists residents with medication and did not have record of required training on file. This 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. PRN authoriztion letter from the physician not on file for resident #5 (PRN medication prescribed). This 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. Two (2) out of five (5) residents records reviewed did not have an updated annual medical assessment. This 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. Cleaning supplies observed under the sink cabinet 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 as five out of five LIC622, were incorrectly filled out and had medications missing on the list of medications (Amlopidine and Duloxetine) 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 one out of one resident's hospice information was not available for review at the time of the inspection, which poses/posed a potential health, safety or personal rights risk to persons in care.

87615(a)(1) Prohibited Health Conditions. (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained...: (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by: Based on the information obtained, record review and interviews, the licensee did not comply with the section cited above, as the Resident sustained pressure injuries while in care, and developed a stage four (4) sacral wound, and was retained in the facility with a prohibited health condition, which poses an immediate health and safety risk to residents in care.

87631 (a)(3)(A)(B) Healing wounds: Residents with a stage one or two pressure injury must have the conditiondiagnosed by a physician… (A) The resident shall receive care for the pressure injury from a physician or an appropriately skilled professional; (B) All aspects of care by... facility staff shall be documented in the resident's file. This requirement is not met as evidenced by: Based on the interviews, staff provided care for pressure injuries, which can only be cared by a skilled professional, which poses an immediate health and safety risk to residents in care.

87466-The licensee shall ensure that residents are regularly observed for changes in physical...When changes such as …a physical health condition are observed, the licensee shall ensure that such changes are... brought to the attention of the resident's physician and ... This requirement was not met as evidenced by: Based on the investigation, staff failed to timely observe R1s change in physical health condition, which poses an immediate health and safety risk to residents in care.

87468.1(a)(2) Personal Rights of Residents in All Facilities: (a) 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...This requirement is not met as evidenced by: Based on observation, and interviews conducted, the Licensee did not comply with the section cited above, staff did not conduct initial screening for COVID-19 symptoms of individuals entering facility, while providing care and supervision to residents in care, which poses a potential health and safety risk to residents in care.