CARRIAGE HOUSE

Official classification

Type A

Official code

87629(a)

Regulation authority

CCR

What the official deficiency says

87629(a) Injections - The licensee shall be permitted to accept or retain a resident who requires intramuscular, subcutaneous, or intradermal injections if the injections are administered by the resident or by an appropriately skilled professional. This requirement is not met as evidenced by: Deficient Practice Statement 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.

Official plan of correction

POC Due Date: 10/15/2025 Plan of Correction Licensee/Administrator to ensure they obtain a written, dated, and signed Dr's Order that R5 can handle and provide their own insulin injections as needed. POC due 10/15/25.

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

87203 Fire Safety- All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by: Deficient Practice Statement 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.

Official plan of correction

POC Due Date: 12/05/2024 Plan of Correction The Administrator stated they have an estimate to have the gate and it's side fencing redone and balanced as needed, so the fire exit gate works appropriately. Administrator will submit plan of correction for repairing/redoing the fire exit gate so it works appropriately. Ensure all staff are aware and trained on ensuring the opening of the fire exit gate in the event of an emergency. The fire exit gate will be repaired/redone in a timely manner, which will be within a two week time frame. Follow-up by 12/18/24 with photos, and written statement on how the fire exit gate was repaired/redone and is working appropriately. POC due 12/5/24.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement 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.

Official plan of correction

POC Due Date: 12/29/2023 Plan of Correction Licensee/Administrator to ensure the facility is conducting quarterly emergency drills as required. Submit plan of compliance with the H & S 1569.695(c). Licensee to conduct a facility emergency drill with staff, on every shift, and submit a copy of the drill along with facility compliance plan. POC due 12/29/23.

Official classification

Type B

Official code

1569.652

Regulation authority

HSC

What the official deficiency says

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.

Official plan of correction

Licensee to submit facility’s plan of ensuring any due refunds are reimbursed as required and that financial records are accurate; Licensee to also provide proof that resident's responsible party has been reimbursed and received the due refund per law/HSC. POC due no later than 12/10/21.

Deadline recorded: Dec 10, 2021. A deadline is not proof that correction was completed.