Angel Haven

HEALTH & SAFETY CODEEach employee who received training and passed the exam required... and who continues to assist with the self-administration of medicines, shall also complete 8 hours of in-service training on medication-related issues in each succeeding 12 month period. This requirement is not met, as there is no evidence that staff received 8 hours of medication training in 2025. Records show that staff received 6 hours of med training in 2025. Licensee failed to ensure that staff received required 8 hours of med training.

All RCFEs shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care...shall include 4 hours of training on the care, supervision, and special needs of those residents... 4 hours of training thereafter...per year.... This requirement is not met, as there is no evidence that staff received training on postural supports and restricted health conditions, which poses a potential health, safety or personal rights risk.

POSTURAL SUPPORTSBed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.This requirement is not met, as there are 2 half bed rails on bed for client #5, but full bed rails are not included in hospice care plan. Licensee failed to ensure that hospice care plan includes full bed rails for client #5, which poses a potential health, safety or personal rights risk to clients in care.

Ensure hazardous items are locked and not unattended

STORAGE SPACEThe licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage.This requirement was not met, as Comet cleansers are stored in cabinets in 2 bathrooms used by clients. Licensee failed to ensure that cleaning products are stored in secure area, inaccessible to clients. This poses an immediate health, safety or personal rights risk to clients in care.

PERSONAL ACCOMMODATION SVCSThe licensee shall ensure provision of bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers. This requirement was not met, as there are no night stands or reading lamps in at least 4 out of 6 rooms, which poses a potential health, safety, or personal rights risk to clients in care. Licensee failed to ensure that all residents are provided with required furnishings.No nightstands and reading lights in rooms of C1, C2, C3, C6

MEDICAL ASSESSMENTSThe medical assessment shall include...a physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for... communicable tuberculosis. This requirement is not met, as TB test results are not maintained for 3 out of 6 residents. Licensee failed to ensure that all clients have TB test results on file, which poses a potential health, safety or personal rights risk to clients in care. Clients #1, #2, #6 do not have TB test results on file.

Label and preserve medicine compliance standards

INCIDENTAL MEDICAL CARENo persons other than the dispensing pharmacist shall alter a prescription label.This requirement was not met, as start dates are written on Rx labels by staff. Licensee failed to ensure that no one alters Rx labels, which poses a potential health, safety, or personal rights risk.

ADMISSION AGREEMENTSAdmission agreements shall specify... payment provisions, including...rate for all basic services which the facility is required to provide.This requirement is not met, as admission agreements for 2 out of 6 clients do not include monthly rate. Licensee failed to ensure that basic rate is included in signed admission agreements, which poses a potential health, safety or personal rights risk to clients. Monthly rate missing for clients #3 and #6.

POSTURAL SUPPORTSBed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met, as client #4 has full bed rails, but there is no hospice care plan on file. Licensee failed to ensure that hospice client has hospice care plan that includes full bed rails, which poses an immedicate health, safety or personal rights risk to clients in care.

HOSPICE CAREA current and complete hospice care plan shall be maintained in the facility for each hospice resident and include specific information.This requirement was not met, as there are no hospice care plans maintained for 2 out of 3 hospice residents. Licensee failed to ensure that hospice care plans are maintained for all those receiving hospice care. This poses a potential health, safety or personal rights risk to clients in care.No hospice care plans for clients #4 and #6.