Routine inspection·September 30, 2025

Citations

20 citations recorded^*CCLD

• 1569.311Type A

  Based on observation, the licensee did not comply with the section cited above when carbon monoxide was not operating during visit, which poses an immediate health, safety or personal rights risk to persons in care.

• 1569.618(c)(3)Type A

  All staff files were reviewed, A1, S2, and S3 did not have current First Aid/ CPR certification on file, this poses an immediately health and safety risk for the residents in care.

• 1569.695(c)Type B

  Based on interviews conducted with Licensee, 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.

• 87202(a)Type A

  Maintain fire clearance before retaining specified persons

  Based on observation, the licensee did not comply with the section cited above when LPA and A1 observed facility exit 5 in room 5 blocked with a metal leaver rod preventing sliding exit door to open, which an immediate health and safety risk which poses an immediate health, safety or personal rights risk to persons 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 R1 had went to the hospital on 07/08/25, 09/19/25, 09/20/25 and when R2 went to the hospital on 09/12/25, 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 in the parlor room on the wall, wall was observed in disrepair in room 2, wall electric outlet was in disrepair in room 5 and in room 6. Electric wall outlet in dining room rock wall not working, poses/posed a potential health and safety and personal rights risk to the resident in care.

• 87303(a)(1)Type B

  Keep bath, laundry and kitchen floors clean

  Based on observation, mold was observed under bathroom sink in room 1 bathroom, which poses a potential Health, Safety, and Personal Rights risk to the resident.

• 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 08:58AM, S1 removing knives from the dishwasher and locking it in shelf over the stove. LPA and A1 observed cleaning chemicals unlock on bathroom 1 tub and in the garage. A gardening tool was observed in the shelf in the garage unlock. accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.

• 87411(F)Type B

  Based on records review, S2 did not have a TB result and good health screening on file. S3 did not have good health screening on file, which poses a potential risk to the health and safety of the residents.

• 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’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 of staff trainings, which poses/posed a potential health, safety or personal rights risk to persons in care.

• 87465(c)(3)Type B

  Document each PRN medication dose taken

  Based on interviews and records reviewed, R2’s medication Lactulose 10gm/15 ml, PRN medication Acetaminophen 325mg, and PRN medication Hydroxyzine HCL 50 mg were not record in the resident’s MAR , which poses a potential health and safety risk for the person in care.

• 87606(c)Type A

  Require fire clearance before non-temporary bedridden admission

  Based on observation and interviews conducted, the licensee did not comply with the section cited above, the facility has no fire clearance for bedridden and has R1 a bedridden resident whose not receiving hospice care reside in room 1, which an immediate health and safety risk which poses an immediate 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 was observed laying in hospital bed with ½ rails on each side. 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.

• 87609(b)(4)Type B

  Agree in writing on agency and facility responsibilities

  Based on record review and interview conducted, the licensee did not comply with the section cited above when LPA review R2’s and R3’s file, whose currently receiving home health with no home health care plan on file, which poses a potential health or personal rights risk to persons in care.

• 87612(a)(2)Type B

  Based on interview conducted, observation, and records reviewed, R1 has a restricted health conditions with no restricted health condition care plan on file or in placed, poses/posed a potential health and safety and personal rights risk to the resident in care.

• 87463(b)Type B

  Document required significant condition changes

  Based on interview conducted, observation, and records reviewed, R1 was admitted to the facility as nonambulatory status and have become bedridden, and no reappraisal was completed for change of condition, 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 S1 observed medication Vitamin C bottle stored in the kitchen drawer next to the stove unlock, which poses an immediate health, safety or personal rights risk to person in care.

• 87465(h)(6)Type B

  Record centrally stored prescriptions and refill data

  Based on interview conducted, observation, and records reviewed, R2’s current medication Lactulose 10gm/15 ml, PRN medication Acetaminophen 325mg, PRN medication Hydroxyzine HCL 50 mg, medication Rifampin were not record in Centrally Stored Medication (Lic 622) record, poses/posed a potential health and safety and personal rights risk to the resident in care.

• 87555(b)(8)Type A

  Food quality controls and rejected damaged goods

  Based on observation, expired perishable foods were observed, poses/posed an immediate health, safety or personal rights risk to persons in care.

FAQ · About this visit

Common questions about this visit

Next steps