Angelic Manor

Based on observation, interview, and record review, the licensee did not comply with the section cited above in that Staff #1 (S1) did not have a criminal record clearance or an exemption 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 two (2) toilet, bath, and shower areas, Bathroom #1, did not maintain individual privacy 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 by not ensuring that Staff #2 (S2) completed the required Health Screening Report 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 by not ensuring that Resident #2 (R2) and Resident #3 (R3) have their Pre-Admission Appraisal in their facility file 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 allowing Resident #3 (R3) to have full bed rail and R3's not on hospice and no letter was submitted to CCLD for approval for the full bed rail 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 by not scheduling a staff to work the night shift, awake and on duty as required for facility with dementia residents 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 by not ensuring that Resident #1 (R1) has an annual medical assessment as required for resident with dementia 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 by not ensuring that the two (2) sharp metal skewers were locked and not accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, interview and record revie], the licensee did not comply with the section cited above by not developing the required Infection Control Plan 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 by not ensuring that Resident #2 (R2) and Resident #3 (R3) have their Pre-palcement Needs & Services Plan in their facility file 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 by not ensuring Staff #2 (S2) and Staff #3 (S3) complete the required 10 hours of Initial Training 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 by not esuring that Staff #2 (S2) and Staff #3 (S3) complete the required 20 hours training annually which poses a potential health, safety or personal rights risk to persons in care.

This requirement is not met as evidenced by interview, observation, and document review, the licensee did not comply with the section cited above evidenced by not having an annual medical assessment completed for Resident’s R1, R2, and R3 which poses a potential health, safety, or personal rights risk to persons in care.

This requirement is not met as evidenced by interview, document review, and observation, the licensee did not comply with the section cited above evidenced by not having a staff file for staff S1 which poses a potential health, safety, or personal rights risk to persons in care.

Postural supports shall be limited to appliances or devices such as braces, spring release trays, or soft ties, used to achieve proper body position and balance... rather than restrict movement... A written order from a physician indicating the need for the postural support... The facility did not meet this requirement as evidenced by failure to obtain a physician's order for the postural support used. This poses a risk to the health and safety of residents in care.