Routine inspection·April 22, 2025

Citations

13 citations recorded^*CCLD

• 1796.45Type B

  Based on records review and interviews conducted, S1 did not have a TB result, which poses a potential risk to the health and safety of the residents.

• 87309(a)Type A

  Ensure hazardous items are locked and not unattended

  Based on observation and interview conducted, staff was using a knife to cook then approximately at 12:19PM left to the room to assist R1 leaving knife on the kitchen counter unattended and unlock, poses/posed an immediate health, safety or personal rights risk to persons in care.

• 87405(a)Type B

  Certified administrator requirements and substitute coverage

  Based on observation and interviews conducted, Administrator works only on Saturday and Sunday and S1 is staff that works Monday through Friday, which poses/posed a potential health and safety and personal rights risk to the resident in care.

• 87405(d)Type A

  Required administrator qualifications listed in this subsection

  Based on observation interview record review, the licensee did not comply with the section cited above due to the amount of citations Administrator is not meeting the requirements of this regulation, which poses an immediate health, safety or personal rights risk to persons in care.

• 87463(b)Type B

  Document required significant condition changes

  Based on interview conducted, observation, and records reviewed, R3 is 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(c)(2)Type A

  Give PRN medication by physician order

  Based on observation, records reviewed, and interview conducted, all the resident’s medication were administrated daily. Medication was checked and MAR was reviewed, all residents’ medications were not administered as instructed by physician which poses/posed an immediate health and safety risk for the person in care.

• 87465(d)(3)Type A

  Record dose details and resident medication response

  Based on observations and records reviewed, R1’s medication Morphine Sulf 100 mg/5ml was not record in the resident’s MAR. R2’s medication Glipizide 5mg and Vitamin @ 1.25 mg were record administered daily for the month of April 2025 and not observed in the facility. At approximately 10:58AM, LPA observed R3’s MARs, staff record all R3’s evening medications were all administered, which poses/posed an immediate health and safety risk for the person in care.

• 87465(i)Type B

  Dispose of unused medications with required witness

  Based on interview conducted, observation, and records reviewed, R2 and R3 destructed medications were stored in food pantry, not record and not destructed, poses/posed a potential health and safety and personal rights risk to the resident in care.

• 87468(a)(6)Type A

  Based on observation and interviews conducted, upon arrival the hall food pantry was locked, which poses/posed a potential health and safety and personal rights risk to the resident in care.

• 87555(b)(25)Type A

  Separate storage for cleaning chemicals

  Based on observation and interviews conducted, at 10:46AM , laundry detergent were observed stored and locked in food pantry with food supplies, which poses/posed a potential health and safety and personal rights risk to the resident in care.

• 87555(b)(26)Type B

  Onsite food stock levels for nonperishables and perishables

  Based on observation and interview conducted, 7 day nonperishable foods were not observed, poses/posed an immediate health, safety or personal rights risk to persons in care.

• 87555(b)(8)Type A

  Food quality controls and rejected damaged goods

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

• 87608(a)(5)(B)Type B

  Based on interview conducted, observation, and records reviewed, all the resident’s current medications 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.