Le Elen Manor, Inc.iv

Type A - §1569.269 Enumerated rights; severability (a) Residents of RCFE shall have all of the following rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement has not been met as evidence by: Based on interviews with residents and staff, the facility Licensee yells at residents resulting in residents are avoiding making eye contact to prevent Licensee from raising their voice at them, which poses an immediate risk to the health and safety of clients in care.

Type B -87468.1 Personal Rights of Residents in All Facilities (a) Residents in all RCFE shall have all of the following personal rights: 11) To have their visitors, including…advocacy representatives, permitted to visit privately during reasonable hours & without prior notice, provided that the rights of other residents are not infringed upon…This requirement has not been met as evidence by: Based on records review and interviews conducted with the Licensee. The Licensee did not ensure the compliance of above regulation due to issuing an addendum to visitation policy to C1 only to discourage C1’s visitors from visiting regularly, which it could be a potential personal rights risk to the residents in care.

§1569.269 Enumerated rights; severability (a) Residents of RCFE shall have all of the following rights: (10) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement has not been met as evidence by: Based on interviews with residents and staff, the Licensee have commented of the smell of the residents, which poses an immediate risk to the health and safety of clients in care.

Based on LPA's observation, records review, and interview with licensee. The licensee did not comply with the section cited above in 2 out of 2 persons which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPA's/Administrator observation and records review, the licensee did not comply with the section cited above by not conducting a drill within the last quarter which poses a potential health, safety or personal rights risk to persons in care.

Based on LPA's/Administrator observation, interview and records review, the licensee did not comply with the section cited above in five out of six residents (R1, R2, R3, R4 and R5) needs their care plan to be updated, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA observation, interview and record review Licensee did not ensure S1 was wearing a mask. Also, staff and residents daily temperatures documented as reflected in facility's mitigation plan and current CCL requirements. This poses an immediate risk to the health, safety and personal rights to the residents in care.