Complaint·October 28, 2025

Citations

13 citations recorded^*CCLD

• 87211(a)(1)Type B

  Report specified resident events within seven days

  Based on record review and interview conducted, LPAs reviewed the residents’ files and observed hospital discharge record for R5 recording R5 had gone to the hospital on 08/09/25 and R3 went to the hospital on 01/16/25. The department did not receive a written report when R3 and R5 went to the hospital, 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, LPAs toured the facility and observed at approximately 09:50AM the air filter was observed full of thick dust in hallway near laundry room, at approximately 09:53AM multiples sacks filled with spiders eggs observed behind laundry room door, and at approximately 10:00AM the right side backyard fence board was broken and spider webs were observed, which 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 LPAs toured the facility at approximately 09:34AM, Clorox disinfecting wipes under the hall bathroom sink unlocked, at 09:35AM, peri care wash bottles unlocked in bedroom #3, at 09:39AM multiple chemicals stored unlock under the kitchen sink, at 09:40AM, sharps in kitchen cabinet next to the stove not properly closed, 09:43AM eye wash solution packets and alcohol pads observed unlock in first aid kit in hallway and a box filled Ensure Max protein nutritional supplement unlock in pantry, at 09:48AM paints in a clear plastic bin on resident desk unlock, and approximately 11:09AM craft paints and a box of acrylic paints under and on top of desk in the livingroom all were accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.

  Read full inspector narrative
• 87465(c)(1)Type A

  Require physician-written PRN medication directions

  Based on record review and interviews conducted, the licensee did not comply with the section cited above when LPAs reviewed R2’s file and observed a handwritten note on a white blank printer paper without a physician’s signature for medication (Alprazolam 0.23 mg) and for crush medications, which poses a potential health or personal rights risk to persons in care.

• 87465(c)(2)Type A

  Give PRN medication by physician order

  Based on observation and records reviewed, LPAs checked R1’s medications, R1’s MAR, and centrally stored medication list. R1’s Tamsulosin Hcl 0.4mg bubble pack filed on 09/29/25 was opened and administered 10/1/25. R1’s MAR record medication Tamsulosin administered daily at 08:00AM from 10/10/25 to 10/28/25. Medication was observed 1 medication Tamsulosin capsule left, which poses/posed an immediate health and safety risk for the person 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 LPAs observed at approximately 09:40AM, medications stored in kitchen cabinet unlocked and accessible to residents, which poses an immediate health, safety or personal rights risk to person in care.

• 87468.1(a)(13)Type B

  Based on interviews conducted and observation, the licensee did not comply with the section cited above when LPAs toured the facility at approximately 09:47AM, R6’s belongings was observed in bedroom 1 walk-in closet locked and only accessible to staff, which poses a potential health or personal rights risk to persons in care

• 87506(b)(17)Type B

  Based on record review, all residents’ files were reviewed. An appraisal (Lic 603) and needs and services plan (Lic 625) was not observed in R2’s file, R3’s Lic 625 was not observed in R3’s file, Medical Consent form (Lic 627C) was not observed in R1 and R4’s files, which poses/posed a potential health, safety or personal rights risk to persons in care.

• 87609(b)(4)Type B

  Agree in writing on agency and facility responsibilities

  Based on record review, the licensee did not comply with the section cited above when LPAS reviewed R1’s file, who’s currently receiving home health with no current home health care plan on file, which poses a potential health or personal rights risk to persons in care.

• 87615(a)(1)(a)Type A

  Based on record review, the licensee did not comply with the section cited above when LPAs reviewed R6’s file and observed notes in hospice plan of care dated 10/14/25 record R6 has Stage 3 wound to right buttock, which poses a potential health or personal rights risk to persons in care.

• 87411(a)Type B

  Facility personnel sufficiency and competence

  87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs… This requirement was not met as evidence by: review of records and LPA observations. The licensee did not comply with the section cited above in that LPA observed 2 unused Lantus Solostar 100unit.ml insulin pens for R4 in refrigerator filled on 3/11/5. Interviews with Licensee, Administrator, staff and R4 disclosed R4 does not get injections as prescribed. No discharge of medication was observed in R4’s file. Interviews with Licensee, Administrator, staff and residents disclosed residents are only being showered 2x weekly and not as needed or requested. This poses a potential health safety and or personal rights risk to residents in care.

  Read full inspector narrative
• 87468.1(a)(1)Type B

  Dignity in personal relationships

  87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidence by: LPA observation. The licensee did not comply with the section cited above in that surveillance cameras in the hallway facing directly into bedroom #1 and bedroom #4. This poses a potential health safety and or personal rights risk to residents in care.

• 87468.2(a)(8)Type B

  Right to freedom from abuse and neglect

  87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement was not met as evidence by: interviews conducted and LPA observations. The licensee did not comply with the section cited above in that interviews confirmed staff would be upset and yell at the residents. LPA observation of resident being transferred by staff with difficulty and a rough manner. The poses a potential health safety and or personal rights risk to residents in care.

  Read full inspector narrative