Routine inspection (multi-day)·August 18, 2025

Citations

6 citations recorded^*CCLD

• 87303(a)Type B

  Maintain facility in clean, safe, sanitary condition

  Based on observation, the licensee did not comply with the section cited abovewhich poses/posed a potential health, safety or personal rights risk to persons in care. LPA found rooms 309 and 311 (share a bathroom) to have sticky floors appearing to have dried liquid. The bathroom floor was sticky and wet with urine, covered with groupings and trails of ants. Room 311 laundry basket linens contained ants. The room has a strons musty stench.

• 87463(b)Type B

  Document required significant condition changes

  Based on interview and record review, 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. It was disclosed that R2 has a change in skin condition. Staff have documented the status of the condition as healing in facility notes. The facility has not conducted a reappraisal of the change of condition or obtained a obtained an updated Medical Assessment to document the skin condition or treatment.

• 87465(a)(4)Type A

  Assist residents with self-administered medication

  Based on record review the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. Per med audit with DON: R1 - Cymbalta -Start date (SD) 7/23/25, there should be 6 pills left in the card, there are 4. R2 -Magnesium Oxide SD 7/30/25, there are 11 pills in the med card, there should be 10. MAR not documented for 8/18/25 am dose. These medications were not given as ordered by physician.

• 87465(c)(3)Type B

  Document each PRN medication dose taken

  Based on record review, 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. LPA and DON conducted a medication Audit. R1's Tylenol 325mg PRN medication documents 7/31/25 on the back of the card. 9 pouches have been used. The MAR only notes on 8/16/25 documentation of the medication dose given to R1. Medications not logged for R1.

• 87465(h)(2)Type A

  Store centrally held medications in locked secure place

  Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. Medications were observed unsecured in the following resident apartments by LPA and AD on 7/29/25. The resident Physician Reports state that the resident cannot store or administer own medications.R3 (136), R5 (110), R6 (119B), R7 (124)

• 87608(a)(5)(B)Type B

  Based on observation], the licensee did not comply with the section cited abovewhich poses/posed a potential health, safety or personal rights risk to persons in care. On 7/29 LPA observed full bed rails on R1's hospital bed and they were removed. On 8/18/25, LPA again observed full bedrails placed on R1's hospital bed. R1 does not have Physician orders for any bed rails at this time.