Lovely Community Healthcare

Ensure hazardous items are locked and not unattended

Based on observation, the licensee did not comply with the section cited above as cleaning solutions were unlocked and accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.

Infection control plan required in operations plan

Based on observation, interview and record review, the licensee did not comply with the section cited above in the infection control plan was not available 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 three (3) meat items did not have proper labels which poses/posed a potential health, safety or personal rights risk to persons in care.

§1569.652 (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...resident’s estate, within 15 days after the personal property is removed.This requirement is not met as evidenced by: Based on interview and record review, the Licensee did not comply with the above cited section, as R1 passed away and all belongings were removed as of 01/06/2025 and correct refund has yet to be issued, which poses a potential personal rights risk to residents in care.

Care of Persons with Dementia (a)This section applies to licensees who accept or retain residents diagnosed by aphysician to have dementia… (4) There is an adequate number of direct care staff to support each resident’s.physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement isnot met as evidenced by: Based on observation and record review, the licensee did not comply with the section cited above as R1 was not provided with adequate care and supervision, which caused R1 to sustain falls and injuries.

Reappraisals-(a)The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changesand to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical,mental... Significant changes shall include but not be limited to: (3) Any illness, injury, trauma, or change in thehealth... (b)The licensee shall immediately bring any such changes to the attention of the resident's physician and hisfamily or responsible person. This requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply with the section cited above as R1 was not provided with adequate care and supervision allowing R1 to cause an injury that required amputation.

Maintenance and operation requirements for facilities

Based on observation, interview and record review, the licensee did not comply with the section cited above. Licensee/Administrator converted the garage area and laundry/closet space in the hallway into a staff room. Licensee/Administrator confirmed live-in staff spend the night in the converted areas. These conversions were not approved or permitted for living/sleeping space. This poses a potential health,safety and personal rights risk to persons in care.

Based on observation, interview and records review, the licensee did not comply with the section cited above. Licensee/Administrator is using full rail for R1 and R2 (non-hospice residents). This poses an immediate health, safety or personal rights risk to persons in care.

Food quality controls and rejected damaged goods

Based on observation, the licensee did not comply with the section cited above as multiple boxes of cereal were found expired along with mayonaise and dressings which poses a potential health and safety risk to persons in care.

Store centrally held medications in locked secure place

Based on observation, the licensee did not comply with the section cited above as medication was observed to be accessible in an unlocked drawer in the kitchen above the locked medication cabinet which poses an immediate health and safety of persons in care.

Keep prescriptions in original containers

Based on observation, the licensee did not comply with the section cited above as medication for R1 was discovered to be in an unlabled container which was identified to be refused medication and to be sent for destruction however medication was not labeled which poses an immediate health and safety risk to persons in care.

87224(d)(B)(1)(2) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts...ferral services that will aid in finding alternative housing. Case management organizations which help manage individual care and service needs. This requirement was not met as evidenced by: Based on record review, the licensee did not comply with the section cited above as the eviction notice did not include referral services and a notice of case management organization which help manage individual care and service needs, which poses a potential health and safety risk to residents in care.

87464(c)The admission agreement shall specify which of the basic services are desired and/or needed by, and will be provided for, each resident.The requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above as the facility is not providing the basic needs care outlined per the Admissions Agreement signed and dated on 8/17/2017, which poses a potential health and safety risk to residents in care.

Provide resident hot water for personal care

Based on LPA’s observation, the licensee did not comply with the section cited above as the resident bathroom faucets deliver hot water measured between 124- and 125.8-degrees Fahrenheit, which poses an immediate health and safety risk to persons in care.

Admission agreement signing and dating deadline

87507(c) Admissions Agreement. Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident… and the licensee no later than seven days following admission…This requirement is not met as evidenced by: Based on interviews and record review, the licensee failed to comply with the section cited above as R1 does not have a signed admission agreement on file which poses a potential personal rights risk to residents in care.

Fire approval and staff access to unlock systems

87705 Care of Persons with Dementia (f)(2) The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. 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 items were observed in an accessible location to residents which posed an immediate health risk to persons in care.