Routine inspection (multi-day)·January 12, 2026

Citations

7 citations recorded^*CCLD

• 87202(a)Type A

  Maintain fire clearance before retaining specified persons

  87202 Fire Clearance(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.This requirement is not met as evidenced by: Based on observation & interview, th facility did not comply with the regulation listed above, which poses an Immediate health and safety risk to residents in care. Emergency exit was not free from obstruction. LPA observed various boxes obscuring the exit from the house through the garage.

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• 87309(a)Type A

  Ensure hazardous items are locked and not unattended

  87309 Storage Space and Access(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.This requirement is not met as evidenced by: Based on observation, interview, and record, facility did not comply with the regulation listed above, which poses an Immediate health and safety risk to residents in care. LPA observed a pair of scissor & knife in an unlocked kitchen drawer. LPA also observed tools, paint, and other toxic solutions unlocked and accessible in the facility’s garage.

• 87465(6)Type B

  87465 Incidental Medical and Dental Care(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.This requirement is not met as evidenced by: Based on observation, interview, and record, facility did not comply with the regulations listed above, which poses a potential health and safety risk to residents in care. LPA reviewed centrally stored medication log which for R1 which did not have matching information from the dose on the bottle, MARS, and centrally stored.

• 87465(h)(2)Type A

  Store centrally held medications in locked secure place

  87465 Incidental Medical and Dental Care(h) The following requirements shall apply to medications which are centrally stored:(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.This requirement is not met as evidenced by: Based on observation & interview, the facility did not comply with the regulation listed above, which poses an Immediate health and safety risk to residents in care. LPA observed medication in a unlocked cabinet in the kitchen and allergy medication in a resident’s room.

• 87555(b)(15)Type A

  87555 General Food Service Requirements(b) The following food service requirements shall apply:(15) All persons engaged in food preparation and service shall observe personal hygiene and food services sanitation practices which protect the food from contamination.This requirement is not met as evidenced by: Based on observation, interview, and record, facility did not comply with the regulation listed above, which poses an Immediate health and safety risk to residents in care. LPA observed knives to be locked and under the kitchen sink next to a hand dustpan and other cleaning items. medication in a unlocked cabinet in the kitchen and allergy medication in a resident’s room.

• 87633(6)Type B

  87633 Hospice Care of Terminally Ill Residents(6) Identification of the training needed, which staff members need this training, and who will provide the training relating to the licensee’s responsibilities for implementation of the hospice care plan.This requirement is not met as evidenced by: Based on observation, interview, and record, facility did not comply with the regulation listed above, which poses a potential health and safety risk to residents in care. LPA reviewed R1 & R2 records and did not find verification of staff training for resident's hospice care plan. Administrator stated they did not have a hospice plan on file.

• 87633(4)Type B

  87633 Hospice Care of Terminally Ill Residents(4) A written hospice care plan which specifies the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the facility is developed for each terminally ill resident or prospective resident by that resident’s hospice agency and agreed to by the licensee and the resident, or prospective resident, or the resident’s or prospective resident’s Health Care Surrogate Decision Maker, if any, prior to the initiation of hospice services in the facility for that resident, and all hospice care plans are fully implemented by the licensee and by the hospice(s).This requirement is not met as evidenced by: Based on observation, interview, and record, facility did not comply with the regulation listed above, which poses a potential health and safety risk to residents in care. LPA reviewed R1 & R2 records and did not find a hospice care plan. Administrator stated they did not have a hospice plan.

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