Ebadat Residential Care Home #4

Based on record review, the licensee did not comply with the section cited above in that 2 out of 3 residents' Appraisal Needs and Service plan were not signed by the facility and the facility staff which poses/posed 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 that 2 out of 3 residents' admission agreements were not signed by the family and the facility 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 ensure staff are trained on dementia care while retaining residents with dementia which poses a potential health, safety, and personal rights risks to persons in care.

Based on observation, interview, and record review the licensee did not ensure residents appraisal needs and services plans were updated yearly and as often as needed to ensure accuracy which poses a potential health, safety, and personal rights risk to persons in care.

Based on observation, interview, and record review the licensee did not ensure the residents files were up to date to contain all required documents which poses a potential health, safety, and personal rights risk to persons in care.

Based on observation, interview and record review the licensee did not ensure to maintain the facility's plan of operation / dementia plan of operation on file in the facility for licensing review which poses a potential health, safety, and personal rights risk to persons in care.

(a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by: Based on observation, interview, and record review the licensee built-in 2 bedrooms in the garage to house 3 live-in staff without obtaining a permit and approval which poses an immediate health, safety, and personal rights risk to persons in care.