Follow-up on corrections·November 13, 2025

Citations

9 citations recorded^*CCLD

• 1569.269(a)(6)Type A

  §1569.269 Enumerated rights; severability (a)(6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on file review, interviews conducted and record review, the licensee did not ensure that facility was staffed sufficiently or that staff were competently trained to ensure injuries were not caused to R1 during their care, which poses a health, safety, and/or personal rights violation to residents in care.

• 1569.625Type B

  H&S Code 1569.625 Staff training; legislative findings; contents: training requirements . This requirement is not met as evidenced by: ***Based on file review & interview with Licensee, the licensee failed to ensure that all staff had completed the required annual training as required by title 22 regulations and H&S Code which poses a potential health and safety risk to residents in care. LPA observe during file reviews 3 out of 3 staff have not completed all of the required 20 hours of ongoing annual training.

• 87211(a)(1)(D)Type B

  87211 Reporting Requirements:(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by: Based on records reviewed Licensee did not follow regulation by not notifying the Department of a residents visit to the emergency room. This poses a potential Health, Safety or Personal rights risk to residents in care.

• 87412(c)Type B

  Document required staff training and orientation

  87412 Personnel Records:(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not met as evidenced by: Based on records reviewed, Licensee did not have documentation of completed staff training. This poses a potential Health, Safetly or Personal Rights risk to residents in care.

• 87468.1(a)(9)Type B

  Prompt responses to resident communications

  87468.1 Personal Rights of Residents in All Facilities: (9) To have communications to the licensee from their representatives answered promptly and appropriately. This requirement is not met as evidenced by: Based on interviews conducted, Licensee did not promptly respond to resident representatives This poses a potential personal rights risk to residents in care.

• 87507(e)Type B

  Provide copies of signed agreements and amendments

  87507 Admission Agreements:(e) The licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative, if any, immediately upon signing the admission agreement or modification. This requirement is not met as evidenced by: Based on interviews conducted, resident nor their representative received a copy of the admission agreement immediately after signing. This poses a potential Health, Safety or Personal rights risk to residents in care.

• 87608(a)(5)(B)Type B

  87608 Postural Supports (a)(5)(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Based on file review, interviews conducted and record review, the licensee was unable to produce orders for full bedrails observed on R1's hospital bed as required per regulation, which poses a potential health, safety, and/or personal rights violation to residents in care.

• 85068.2(b)Type B

  85068.2(b) Needs and Service Plan. If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan…..***Based upon records reviewed, this requirement has not been met as evidenced by: Appraisal & Needs Service Plan for 5 out of 5 residend as of 04/01/2025 is not complete or signed by all partiesThis poses a potential Health and Safety risk to clients in care.

• 87465(a)(4)Type A

  Assist residents with self-administered medication

  87465 Incidental Medical and Dental Care:(4) The licensee shall assist residents with self-administered medications as needed.This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, Licensee did not ensure medications were administered as ordered. Resident did not receive eye drops as ordered and resident antibiotics were not given as ordered. This poses an immediate Health risk to residents in care.