Angelic Hands Assisted Living

85066 Personnel Records(b) A dated employee time schedule shall be developed at least monthly, shall be displayed conveniently for employee reference and shall contain the following information for each employee: (1) Name. (2) Job title. (3) Hours of work. (4) Days off. This requirement is not met as evidenced by: Based on observation and interview, the licensee did have a personnel roster which poses a potential health, safety or personal rights risk to persons in care.

87506 Resident Records(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Based on observation and interview, the licensee did have a record of one resident, which poses a potential health, safety or personal rights risk to persons in care.

80088Furniture, Fixtures, Equipment, and Supplies(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).This requirement is not met as evidenced by: Based on observation and interview, licensee did not meet this requirement evidenced by the hot water temperature measuring at 132.4 degrees, 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 due to staff residing in a common area (nook) that was not established in the facility sketch provided to CCL which poses a potential health, safety or personal rights risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above in three (3) out of four (4) residents are under the age of 60, exceeding the departments limitation of accepting a resident under the age of 60 in a resident care facility for the elderly (RCFE) which poses a potential health, safety or personal rights risk to persons in care.

Termination of admission agreement upon death of residen...refund of fees paid...and refunds: (a) A residential care facility for the elderly shall not require advance notice ...upon the death of a resident. No fees shall accrue once all personal property...is removed... This requirement was not met by: Based on interviews conducted, the Licensee did not comply with the above regulation with at least one resident. LPA Colvin confirmed that R1's family did not receive a refund for fees prepaid for R1 through 10/18/22. R1 passed away and proprty removed 9/29. This is an immediate personal rights violation of R1.

Admission Agreements: (e) The licensee shall provide a copy of the signed and dated current admission agreement,...to the resident or the resident's representative...immediately upon signing the admission agreement... This requirement was not met by: Based on interviews conducted, the Licensee did not comply with the above regulation with at least one resident (R1). Administrator does not have proof that a copy was provided to R1's family, and multiple interviews state that no Admisssions Agreement has been received. This is a potential personal rights violation of R1.

Admission Agreements: (g)...shall specify the following: (3) Payment provisions, including the following: (B) Rate for additional items and services, including: 1. A...description of and the corresponding fee schedule for all additional items and services not included in the fees for basic services... The Licensee did not comply with the above regulation with at least one resident. LPA Colvin observed that R1's agreement had written in additional services (hairbuts, transportation), without listing cost of these additional services. This was a potential personal rights violation of R1.

Plan of Operation: (a) Each facility shall have and maintain a current, written definitive plan of operation...Any significant changes in the plan of operation...shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: (2)...Admission Agreement... The Licensee did not comply with the above regulation with at least one resident. LPA Colvin observed that the Admissions Agreement for R1 was entirely different than the Admissions Agreement Licensing has on file from the application for licensure. This is a potential personal rights violation of R1.

Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports... including...: (1) A written report shall be submitted...within seven days of the occurrence of any of the events...(A)Death of any resident from any cause regardless of where the death occurred... The Licensee did not comply with the above regulation with at least one resident. LPA Colvin observed that R2 passed away in September 2022, but Licensing never received a Death Report from the facility.

Resident Records: (d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours.... This requirement was not met as evidenced by: Based on observation and interview, the Licensee did not comply with the above regulation with one resident file. LPA Colvin was unable to access records for R2 during the inspection. This is a potential personal rights violation.

Admission Agreements: (g)...shall..:(5) Refund...(E) Preadmission fees shall be refunded...: 2...fees that are greater than ...($500) shall be refunded...:a. A refund of at least 80 percent...iin excess of $500...resident leaves the facility for any reason during the first month of residency. The Licensee did not comply with the above regulation with at least one resident. R2resided at the facility for less than one month before passing away. Family removed items from facility and was not provided any refund of preadmission fees. This was an immediate personal rights violation of R2.

Resident Records: (d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours.... This requirement was not met as evidenced by: Based on observation and interview, the Licensee did not comply with the above regulation with one resident file. LPA Colvin was unable to access records for R1 during the inspection. This is an immediate safety risk to residents.