An Elite Chateau

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to...the following: (1)A written report shall be submitted to the licensing agency...This requirement is not met as evidenced by: This requirement is not met as evidenced by: Based record review and interview, the licensee did not comply with the section cited above in one (1) out of (6) residents had a medical emergency and then started Hospice Services without notification or report submitted to Licensing which poses an potential health, safety or personal rights risk to persons in care.

(e) The licensee shall supervise residents as needed... when there is use of the following items: (2)...swimming pools...(A) The licensee shall ensure... are inaccessible... when not in active use by residents. This requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply with the section cited above in allowing access to a pool from two gates when not in active use by residents which poses an immediate health, safety or personal rights risk to persons in care.

(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.(1)Documentation of the annual routine visit... added to the resident's record. Based on interviews and record review, the licensee did not comply with the section cited above 1 out of 6 residents having an LIC602 form 2023 even with a change in condition and diagnoses which poses an potential health, safety or personal rights risk to persons in care.

(b) The following food service requirements shall apply: (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 is not met as evidenced by: Based on LPAs' observations, there were no sufficient food supplies for nonperishable foods for a minimum of one week and perishable foods for a minimum of two days on the premises. This poses a potential health, safety, or personal rights risk to residents in care

(h) The following requirements shall apply to medications which are centrally stored:(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.This requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply with the section cited above six (6) out of (6) resdients having medication transfered between containers which poses an potential health, safety or personal rights risk to persons in care.

Criminal Record Clearance. Prior to resi- ding or volunteering.. all individuals... a criminal record review shall obtain a clearance or ..exemption. During visit, LPA met with Administrator's son who is residing in the facility and indicated that his sister also lives here. Based on interview and review of Facility Personnel Report Summary Son & Daughter are not Criminal Background Clearanced or Transferred & Associated to this facility. No documentation has been submitted to CCLD. This poses a potential risk to residents in care.

Based on inspection and observation, the licensee did not comply with the section cited above. The licensee made alteration to the existing facility without prior notification to the Licensing Office which poseshhhnnnn 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 three (03) out of six (06) residents did not have accurate Physician's Report which poses a potential health, safety or personal rights risk to persons in care.