Rose Garden

(a)...(1)Postural supports shall be limited to appliances...soft ties, used to achieve proper body position and balance,..or to position rather than restrict movement including, but not limited to, preventing a resident from falling out of bed, a chair, etc. This requirment was not met as evidenced by: Based on interviews the Licensee did not comply with the regualtion above Administrator used a gait belt to tie a resident to reclining chair which poses an immediate Health, Safety and Personal rights risk to reisdnets in care.

(b) If the licensee is a corporation or an association, the governing body shall be active, and functioning in order to assure accountability. This requirement was not met as evidenced by: Based on record review the Licensee did not comply with the regulation above, the Incorporation is not in good standing with the Secretary of the State and needs immediate attention which posses a potential personal rights risk to residents in care.

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...This requirement was not met as evidenced by: Based on interviews the Licensee did not comply with the regulation above, the facility will need additional staffing to take care of R1 due to change in condition and meeting R1's needs which posses a potential Health, Safety and Personnel rights risk to residents in care.

Based on record review, the licensee did not comply with the section cited above in staff where not meeting the 20 hours of annual trianing which poses 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 LPA ran Barnhill & Barnhill Inc. and on the SoS showing inactive as of 03/27/2019 which poses a potential health, safety or personal rights risk to persons in care.

Based on record review and interviews, the licensee did not comply with the section cited above in quarterly emergency drills were not completed for the past year 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 that the stove had knobs (6) allowing residents to turn on the stove which poses a potential health, safety or personal rights risk to persons in care.

Based on observations, the licensee did not comply with the section cited above in that knives and scissors were stored in an unlocked kitchen cabinet which poses a potential health, safety or personal rights risk to persons in care.

Based on record review and interviews, the licensee did not comply with the section cited above in five out of five staff did not complete annual required training which poses 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 out of five staff did not have a background clerance which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review and interviews, the licensee did not comply with the section cited above in that documentation is not available showing proof of liability insurance which poses a potential health, safety or personal rights risk to persons in care.

Based on record review and interviews, the licensee did not comply with the section cited above in S2 had an expired first aid certification 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 that cleaning supplies were in an unlocked kitchen cabinet accessible to residents in care which poses a potential health, safety or personal rights risk to persons in care.

87468.1 – Personal Rights. Residents have the right to be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on observations, the facility failed to ensure staff were wearing face coverings which poses an immediate health, safety and personal rights risk to residents in care.

...c. A refund of at least 40 percent of the preadmission fee in excess of $500...during the third month of residency. This requirement was not met as evidenced by: Based on documentation the Licensee did not comply with the AA and did not issue a refund of 40% of the pre-admission to the RP which poses a potential personal rights risk to the residents in care.

...(d)... a licensee shall, within three days of becoming aware of the resident’s death...written notice of the facility’s policies...and refunds. This requirement was not met as evidenced by: Based on documentation the Licensee did not comply with R1’s admission agreement to provide written communication regarding refunds which poses a potential personal rights risk to residents.