Ashley's Manor Ii

Based on record review, the licensee did not comply with the section cited above as 3 out of 6 residents has no capacity for self-care and is not on hospice and the facility does not have an approved exception with the Department, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above as all residents had full rails and only one resident is receiving hospice care which poses a potential health, safety or personal rights risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above by having a bedridden resident in room #3. Facility license is approved for 6 non-ambulatory residents only which poses an immediate health, safety risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above by not having current needs and service plan with responsible parties' signatures which poses 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 as during the facility tour at 3:50PM, LPA and Licensee observed the following items in the shared bathroom: bleach, and wound cleanser which poses an immediate safety risk to persons in care.

Based on observation, interview, and record review, the licensee did not comply with the section cited above as when LPA arrived at the facility Staff #1 (S1) was working alone and has been working for 2 (two) days, but S1's criminal background clearance was not transferred to this facility prior to working with residents, which poses an immediate safety risk to persons in care.

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This requirement is not met as evidenced by: Based on interview and observation, Licensee did not allow R1 to return to R1's room at the facility when the hospital requested discharge, which poses an immediate personal rights risk to residents in care.

87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.This requirement is not met as evidenced by: Based on interview and observation, the licensee/administrator was unable to provide staffing and refused to allow R1 to return to the facility upon hospital discharge, which causes an immediate safety and personal rights risk to residents in care.

1569.269 Enumerated rights; severability (a) Residents... have all of the following rights: (22) To be protected from involuntary transfers, discharges, and evictions... “involuntary” means a transfer, discharge, or eviction that is initiated by the licensee, not by the resident.This requirement is not met as evidenced by: Based on interview, the Licensee transfered R1 to the hospital and refused re-admission to the facility, which poses an immediate threat to the health and safety of residents in care.

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia:...This requirement is not met as evidenced by Based on LPA's observations, the licensee did not comply with the section cited above as toxic substances, gardening suppies, and disinfectant were observed throughout the facility accessible to residents which posed an immediate health risk to persons in care.