Country Rose Assisted Living

Based on LPA's/staff observation, records review and interview, the licensee did not comply with the section cited above by not obtaining a valid administrator certification after their certificate expired in 2024, which poses a potential health, safety or personal rights risk to persons in care.

Based on LPA's/staff observation and interview, the licensee did not comply with the section cited above by ceiling needs patchwork which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA's/staff observation, interview and record review, the licensee did not comply with the section cited above in one out of three staff did not have health screening including TB test on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Based onLPA's/staff observation, interview and record review, the licensee did not comply with the section cited above by not maintaining a Centrally Stored Medication Log which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA's/staff observation, interview and record review, the licensee did not comply with the section cited above in one out of four residents do not have a bed rail form on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA's/staff observation, interview and record review, the licensee did not comply with the section cited above in two out of four resident's care plans where not signed by their responsible parties which poses/posed a potential health, safety or personal rights risk to persons in care.

Type B - 87211(a)(1)(D) Reporting Requirements. The licensee shall send a written report, within seven days, to the licensing agency and the person responsible for the resident when any incident occurs which threatens the welfare, safety or health of any resident. This requirement is not met as evidenced by: Based on LPAs interviews and record review the facility failed to submit an incident report for R1 incident which required hospitalization which poses a potential health and safety risk to residents in care.

Type B - 87506 Resident Records (d) All resident records shall be available to the licensing agency to inspect, audit, & copy upon demand during normal business hours…This requirement was not met as evidence by: Based on LPA's record review and interview with Licensee, the facility did not have available resident’s (R1, R2, R3 & R4) care plans when requested by CCL, which poses a potential health and safety risk to residents in care.

Based on LPAs/Licensee observation, interview and record review, the licensee did not comply with the section cited above in two out of three staff did not have a health screening including TB on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPAs/Licensee observation and interview, the licensee did not comply with the section cited above in eleven food containers with grains, beans, rice, etc were not storage in a safety manner by not having expiration and open dates on them which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPAs/Licensee observation, interview and record review, the licensee did not comply with the section cited above in two out of five residents do not have an updated care plan on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA/staff observation, records review and interviews with the licensee, the licensee did not comply with the section cited above in one out of five residents (R2) when spot of medications and their records were reviewed. R2 have not been given their medication as prescribed by their physician which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPA/staff observation, records review and interview with the licensee, the licensee did not comply with the section cited above in five out of five resident's medications where not entered into the Centrally Stored Medication log accordingly which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA/staff observation, records review and interview with licensee and resident (R2) in care, the licensee did not comply with the section cited above in one out of five residents (R2) who is bedridden was properly located in a bedroom that it was cleared by the Fire Department as a bedridden room, which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPA/staff observations and interviews with the licensee, the licensee did not comply with the section cited above in three food items located in the food pantry of the facility that were found expired which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPA’s records review and interviews conducted with Licensee did not ensure that CCL was notified of incident involving R2's hospitalization, which poses a potential health & safety risk to residents in care.

Based on LPA/staff observation, records review and interview with licensee, the licensee did not comply with the section cited above by not ensuring that staff (S1) had a complete personnel file which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, interview, the licensee did not comply with the section cited above in one out of one fireextinguisher has not been serviced within the last year 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 toxins including disinfectants were unlocked and accessible to residents in care under the sink located in resident's bathroom which poses an immediate health, safety or personal rights risk to persons in care.

87412 Personnel Records (g) All personnel records shall be maintained at the facility & shall be available to the licensing agency for review. (1) The licensee shall be permitted to retain such records in a central administrative location provided that they are readily available to the licensing agency at the facility as specified in Section 87412(f). Based on observation, interview and record review, the licensee did not comply with the section cited above not having records available for Licensing to review during visit including updated personnel report which poses a potential health and safety risk to persons in care.

Based on LPA observation, interview and records review Licensee did not ensure that staff and residents are being monitored daily for symptoms of Covid19 and results 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.

1569.269(a)(21)H&S.Residents of residential care facilities for the elderly shall have all of the following rights:… To have prompt access to.. records. Photocopied records shall be promptly provided, not to exceed two business days.....*** Based upon statements made and records reviewed, this requirement has not been met as evidenced by: Facility received written request for records on March 25,2021 and, as of April 20, 2021, the facility has not provided the records. This poses a potential violation of R1’s personal rights.