Complaint·September 11, 2025

Citations

5 citations recorded^*CCLD

• 87202(a)Type A

  Maintain fire clearance before retaining specified persons

  87202(a) - (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 was not met as evidenced by: Licensee did not ensure approved fire cleareance was maintained by attaching latch locks on the outside of the main builiding, on top of the door, locking residents in facility which poses an immediate health, safety, and/or personal rights risk to resident in care.

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• 87465(a)(4)Type A

  Assist residents with self-administered medication

  (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Licensee did not ensure R1's medication were issued as prescribed. LPAs observed the Centrally stored medication log for R1 has a start date of 09/01/2025; however, medication bubble pack has a label indicating Date Opened is 09/05/25. Medication bubble pack shows eight pills out of 28 were administered for the evening and the bubble pack for the morning shows seven out of 28 were administered for the morning,which poses an immediate health, safety, and/or personal rights risk to resident in care.

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• 87465(a)(6)Type B

  Maintain records of centrally stored medication dosages

  (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (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 was not met as evidenced by: Licensee did not ensure R1 and R2 had a centrally stored log for August of 2025, which poses a potential health, safety, and/or personal rights risk to residents in care.

• 87465(h)(4)Type A

  Label and preserve medicine compliance standards

  87465(h)- The following requirements shall apply to medications which are centrally stored:(4) -All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement was not met as evidenced by: Licensee did not ensure prescription labels remained unaltered. LPAs observed the time for R1 to take a prescribed medication at noon was altered to indicate to take at 2 PM, which poses an immediate health, safety, and/or personal rights risk to resident in care.

• 87633(a)(4)Type B

  Each terminal resident needs a written hospice care plan

  (a)The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility when all of the following conditions are met:(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 was not met as evidenced by: Licensee did not ensure R2 had a Hospice Care Plan, which poses a potential health, safety, and/or personal rights risk to residents in care.

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