Carriage House

Per LPA's record reviews, R5 is diabetic, and needs insulin injections, per medical assessment of 8/12/25, and medication records, R5 has a meter that reads blood-glucose levels. Per interview with staff S1, R5 does own insulin injections 3xs a day. Per medical assessment, R5 is not able to provide own injections or handle own medications; There is no Dr's Order that R5 is able to provide own injections or self inject the insulin KwikPen as needed, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPA's observation the backyard fire exit gate is broken, a bit slanted down, is large and heavy, and not able to open freely as needed during an emergency. LPA obtained photos, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPA's review of facility records, and staff interviews, there have been no emergency drills conducted as required, quarterly drills; One of the quarterly drills must be a facility evacuation drill. The last drill per record review was in 2019, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.

HSC-1569.652 Termination of admission agreement upon death of resident; removal of resident’s property; refund of fees paid; notice of contract termination and refunds. (c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed. Licensee did not meet this requirement based on financial record reviews, email reviews, and Interviews with Licensee, and other party(s). Per LPA’s review, the refund was requested twice, and Licensee responded to the 2nd request on 11/29/21 that she would have her accountant mail out a check today. Licensee confirmed to the LPA that she had not refunded the responsible party (RP) within 15 days as required for a resident who passed away and whose personal belongings were moved out by 9/22/21. Licensee stated that she has sent out a refund to the responsible party (RP) and she will be notified when the RP receives due refund. This is a personal rights violation.