Hovley Care Llc

Based on record review, the licensee did not comply with the section cited above in paying their annual licensing fee since the year 2021 which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on interview, the licensee did not comply with the section cited above in conducting a quarterly disaster drills with staff which poses/posed 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 for Resident One (R1) who did not have a updated record of the centrally stored medication list, the most recent list is dated 03/14/2024 which 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 in two (2) out of two (2) staff who do not have documentation of the training available for review during the visit which poses/posed a potential health, safety or personal rights risk to persons in care.

Personal Rights;To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups This requirement is not met based as evidence by interview. The licensee did not comply by barging into resident’s bedroom without knocking and not accord resident personal privacy which poses a potential health, safety, or personal rights risk to persons in care

Personal Rights;(a) Except .... each client shall have personal rights which include, but are not limited to, the following:(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature.... This requirement is not met based as evidence by interview. The licensee did not comply by yelling at resident 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 zero (0) carbon monoxide alarms are in the facility, which poses an immediate health, safety or personal rights risk to persons in care.

During annual, LPA observed and through interview and record review, the licensee did not comply with the section cited above in not reporting to CDSS any serious incident reports, which poses an immediate health, safety or personal rights risk to persons in care.

Personnel Records: (g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review. This requirement was not met as evidenced by: Based on observations and interviews, the Licensee did not comply with the above regulation with all staff files. LPA Colvin was unable to review staff files as they were not on site and not provided to LPA Colvin during the inspection. This is a potential safety and personal rights violation to all residents.

Civil penalties...for deficiencies: (c) The department shall assess an immediate civil penalty of five hundred dollars ($500)...for any of the following serious violations: (2) (A) Fire clearance violations, including, but not limited to...inoperable smoke alarms... This requirement was not met as evidenced by: Based on observations and interviews, the Licensee did not comply with the above regulation with 1 of 6 smoke detectors. LPA Colvin observed the smoke detector in the hallway in-between the resident bedrooms on the right of the facility to be inoperable. This is an immediate safety hazard for all residents.

Residents requiring skilled nursing or intermediate care; bedridden residents: (a) ...no resident shall be admitted or retained in a residential care facility for the elderly if any of the following apply: (2) The resident is bedridden...This requirement was not met as evidenced by: Based on record review, the Licensee did not comply with the above regulation with 1 of 4 residents (R1). LPA Colvin observed in R1's Phsycian's Report dated 2/25/21 that R1 is bedridden. The facility is licensed and has fire clearance for non-ambulatory only. This is an immediate safety risk for R1.

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 evidenced by: Based on observation and interviews, the Licensee did not comply with the above regulation with two facility appliances/fixtures. LPA Colvin observed the kitchen microwave and kitchen sink to be in disrepair (start button on microwave and leaking sink pipes). This is a potential personal rights violation.

On and after 07/01/15, all RCFEs...shall maintain liability insurance covering injury to residents and guests in the amount of at least $1,000,000 per occurrence and $3,000,000 in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by: Based on records review, the licensee failed to ensure that the facility had proof of liability insurance. The facility has not provided proof of liability insurance from 09/01/2018 until this date, 04/07/2021. This posed a potential health and safety risk to the residents in care.