Indian Peak Manor

Based on (observation), the licensee did not comply with the section cited above in bedroom four (4). Window screen shall be replaced, as the screen does have a hole. Screens shall also be regularly maintained 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 in both sinks in bathroom number two (#2) are currently clogged, 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. LPA did not observe that the administrator recertification requirements were met which poses a potential safety and personal rights risk to persons in care. LPA had the discussion with Glenda Marquez.

Based on record review, the licensee did not comply with the section cited above for three out of five resident which poses a potential health rights risk to persons in care. LPA did not observe an annual medical assessments (LIC 602) nor reappraisals for residents #3, #4, and #5 diagnoised with dementia. LPA and staff reviewed the files together.

87208 Plan of Operation(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:(1) Statement of purposes and program goals. This requirement was not met as evidence by: Based on observation and records review, the licensee failed to follow the original facility's Plan of Operations and Admissions Agreement in having four small dogs living inside the facility. This poses a potential health and safety risk to all residents in care.

87303 Maintenance and Operation(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by: Based on observations and photographs, the licensee failed to keep the facility in good repair at all times, having a broken mirror door closet in one of the resident's rooms and rusted closet railings in 3 residents' rooms. This poses a potential health and safety risk to all residents in care.

87309 Storage Space(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met as evidenced by: Based on observation, during a physical tour of the facility, LPA observed cleaning solutions not locked under the kitchen sink. This violation poses an immediate health and safety risk to clients in care.