Routine inspection·January 14, 2026

Citations

9 citations recorded^*CCLD

• 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 a knife inside the kitchen sink unlock and laundry detergent on the floor in the laundry room unlock accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.

• 87405(d)(2)Type A

  Conformance with applicable laws and regulations

  Based on observation, Fire Extinguisher has a service date of 01/06/25, which poses an immediate health and safety risk to the residents.

• 87458(c)(1)(A)Type B

  Record findings for communicable tuberculosis conditions

  Based on records reviewed, R4 do not have TB result on file which poses/posed a potential health, safety 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, 5 out of 15 of R5’s medications were checked by LPA and Administrator and observed not administered as directed by physician. Staff did not record medications administered for all 6 residents on 01/14/26 at 08:00AM, 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, 8 out of 15 medications for R5 were not recorded in the resident’s MAR. Staff did not record medications administered for all 6 residents on 01/14/26 at 08:00AM, which poses a potential 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 LPA observed staff taking medication cup filled with medication tablets out of an unlock kitchen drawer, 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, all of current R3,R4, R5 and R6’s medications were not recorded in Centrally Stored Medication (Lic 622) record, poses/posed a potential health and safety and personal rights risk to the resident in care.

• 87608(a)(3)Type B

  Maintain physician order documentation in resident record

  Based on interview conducted, observation, and records reviewed, R5 uses half bed rail on hospital bed with no doctor’s order, which poses/posed a potential health and safety and personal rights risk to the resident in care.

• 87633(b)Type B

  Facility must keep complete hospice care plan on file

  Based on record review, the licensee did not comply with the section cited above when LPA reviewed R1, R2, and R3 whose currently receiving hospice care with no current hospice care plan on file, which poses a potential health or personal rights risk to persons in care.