Routine inspection·October 2, 2025

Citations

16 citations recorded^*CCLD

• 1569.695(c)Type B

  Based on interviews conducted with Administrator, last emergency disaster drill was completed on 02/2025 and not recorded, which poses/posed a potential health and safety and personal rights risk to the resident in care.

• 87211(a)(1)Type B

  Report specified resident events within seven days

  Based on record review and interview conducted, Licensee did not submit a written report to the department within 7 days of incident when R5 had went to the hospital on 09/26/25, this poses a potential health and safety risk to residents in care.

• 87303(a)Type B

  Maintain facility in clean, safe, sanitary condition

  Based on observation, a hole was observed on the wall by the front door and under the staff bathroom sink is in disrepair, poses/posed a potential health and safety and personal rights risk to the resident in care.

• 87309(a)Type A

  Ensure hazardous items are locked and not unattended

  Based on observation, the licensee did not comply with the section cited above when LPA observed at cleaning solutions under kitchen sink, chemicals under counter in laundry room, a bottle of Hydrogen Peroxide in room 1 bathroom shelf, and paint cans with gardening tool in the backyard all unlock, accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.

• 87411(c)(1)Type A

  First aid training requirements

  Based on interview conducted and records reviewed, all staff files were reviewed and did not have current First Aid certification on file, this poses an immediately health and safety risk for the residents in care.

• 87411(d)(3)Type B

  Resident care and supervision skills

  Based on records reviewed and interviews conducted, R1 is receiving hospice resident requires assistant using Hoyer lift, in which the facility did not provided nor trained on the using the Hoyer lift, This poses a potential health and safety risk to residents in care.

• 87412(a)Type B

  Maintain required personnel records for staff

  Based on record review and interview, the licensee did not comply with the section cited above when A1 and S3’s personnel file was not observed maintained at the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.

• 87412(c)(2)Type B

  Based on record review and interview, the licensee did not comply with the section cited above when all staff files did not have the proper documentation and required trainings, which poses/posed a potential health, safety or personal rights risk to persons in care.

• 87458(b)(1)Type B

  Based on records reviewed, R1 do not have TB result on file which poses/posed a potential health, safety or personal rights risk to persons in care.

• 87465(c)(1)Type A

  Require physician-written PRN medication directions

  Based on interviews conducted, observation, and records reviewed, R3’s medication Medihoney gel was administered as needed by staff with no doctor’s orders, which poses an immediate health, safety or personal rights risk to person in care.

• 87465(c)(2)Type A

  Give PRN medication by physician order

  Based on observation, records reviewed, and interview conducted, R1’s medication Ferrous Sulfate and R5’s medication Melatonin 10mg were checked by LPA and Administrator and observed not administered as directed by physician, which poses/posed an immediate health and safety risk for the person in care.

• 87465(c)(3)Type B

  Document each PRN medication dose taken

  Based on interviews and records reviewed, R1’s medication Melatonin 5mg was not record in the resident’s MAR, which poses a potential health and safety risk for the person in care.

• 87465(h)(6)Type B

  Record centrally stored prescriptions and refill data

  Based on observation and records reviewed, R1’s as needed medication Tylenol 500mg and medication Ferrous Sulfate and R3’s medication Quetiapine 50 mg and medication Amlodipine Sodium 70mg were not record in Centrally Stored Medication record, poses/posed a potential health and safety and personal rights risk to the resident in care.

• 87506(b)(17)Type B

  Based on record review and interview, all residents file were reviewed and observed R3 do not have an appraisal (Lic 603) and needs and services plan (Lic 625) on file, which poses/posed a potential health, safety or personal rights risk to persons in care.

• 87608(a)(3)Type B

  Maintain physician order documentation in resident record

  Based on interview conducted, observation and records reviewed, R1 uses a half rail bed. There is no doctor’s order for ½ rail bed for R1, which poses/posed a potential health and safety and personal rights risk to the resident in care.

• 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 when LPA and A1 observed multiple medications stored under staff bathroom unlock, which poses an immediate health, safety or personal rights risk to person in care.