Post-licensing visit·January 26, 2026

Citations

4 citations recorded^*CCLD

• 87633(b)(6)(B)Type B

  87633 Hospice Care of Terminally Ill Residents(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:(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.(B) The hospice agency will provide training specific to the current and ongoing needs of the individual resident receiving hospice care and that training must be completed before hospice care to the resident begins.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. Facility did not provide R1's training specific to the current and ongoing needs of the R1 receiving hospice care.

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• 87633(d)Type B

  87633 Hospice Care of Terminally Ill Residents(d) The licensee shall ensure that the hospice care plan is current, accurately matches the services actually being provided, and that the client’s care needs are being met at all times.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. Facility did not provide R1's current hospice care.

• 87628(a)Type A

  Allowing diabetic residents based on self-management ability

  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. R’2 physician report indicates they cannot perform their own glucose testing or injections. While conducting interviews it was stated staff perform glucose testing and give insulin injection to R2.

• 87705(f)(2)Type B

  Fire approval and staff access to unlock systems

  Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. There a lock added to the front exterior door which does not have fire clearance approval.