Home of Perpetual Care

(a) All facilities shall maintain a fire clearance approved by the city,city and county fire department. Prior to accepting or retaining any of the followingtypes of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city,or city and county fire department, or the State Fire Marshal. This requirement was not met as evidenced by: R1 is bedridden and the facility fire clearance is not approved for bedridden. This poses an immediate risk to the health, safety, or personal rights of persons in care.

Based on record review, the licensee did not comply with the section cited above in which the licensee did not furnish a report to this agency regarding a recent hospitalization of R1 in April of 2025 due to an illness, 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 which no proof of documentation of emergency drills was provided when requested, 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 which R1 was placed on hospice care on 7/17/25 however, the facility does not have an approved hospice care waiver, which poses an immediate 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 in which R1 had a significant change in health care and licensee did not document these changes on reppraisal, which poses/posed a potential health, safety or personal rights risk to persons in care.

A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days, after the personal property is removed. This requirement was not as evidenced by: Facility did not issue refund within 15 days to R1's responsible party. This poses a potential risk to the health, safety, or personal rights of persons in care.

(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 in comparison with the admission criteria. (1)The appraisal shall document, at a minimum: (A) An evaluation of the prospective resident's functional capabilities, mental condition, and social factors. This was not met as evidenced by: No documentation of R1's pre-appraisal was observed. This poses a risk to the health, safety, or personal rights of persons in care.

(d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications.This requirement was not met as evidenced by: Licensee did not retain original signed and dated admission agreement in R1's resident file. This poses a risk to the health, safety, or personal rights of persons in care.

Based on record review, the licensee did not comply with the section cited above in one out of five residents did not have a physician order for full bed rails 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 one (1) out of five (5) residents are on hospice care and facility did not obtain a waiver 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 facility did not have any records of any drills 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 the facility did not have suffcient supply of 2 day perishable food and 7 day non perishable food 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 LPA observed hospital bed and mattress outside in back yard against wall where shaded patio is at 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 scissors where accessible to residents and R1 was walking around with them during visit with no supervision 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 (1) out of five (5) residents did not have medication that was ordered by physcian at facility 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 residents medication was observd in refrigerator not locked in seprate box 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 one (1) out of three(3) shared bedrooms resident R2 and R3 had a camera in room which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, interview, and record review, the licensee did not comply with the section cited above in admitting and retaining a resident with a primary diagnosis of a mental disorder unrelated to dementia, 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 changing the room occupancy of resident rooms and not providing licensing with a request for approval of change, which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, interview, and record review, the licensee did not comply with the section cited above in installing surveillance cameras in common areas of the facility without an updated plan of operations, which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, interview, and record review, the licensee did not comply with the section cited above in locking a resident's food in a caibinet to keep them from eating too much, 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 broken parts of roof boards above the exit from the living room to the patio and outide the pantry door, which pose a potential health, safety or personal rights risk to persons in care.

Based on observation, interview, and record review, the licensee did not comply with the section cited above in obtaining approval of a dementia care plan in their plan of operations, which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, interview, and record review, the licensee did not comply with the section cited above in an Infection Control Plan submitted and approved to licensing, which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, interview, and record review, the licensee did not comply with the section cited above in auditory devices not installed at entrances and exits, which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review, LPA observed Staff#1 (S1) does not have the health screening and chext x ray result in the file which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA's observation, LPA observed the toilet in the bathroom#2 was not working and its clogged which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA's observation, LPA observed there's no grab in the shower of the bathroom#2 which poses/posed a potential health, safety or personal rights risk to persons in care.