Cheri Grove

Based on documents, S3 has not completed any hours of continuing annual training since January 2025, which poses a potential safety risk to persons in care.

Based on documents, S1's health screening does not have a TB result and the x-ray TB results in S1's file are inconclusive and recommend another scan to be done which is not documented, which poses a potential health risk to persons in care.

Based on documents, the facility did not conduct any emergency disaster drills between May 20, 2025 and January 16, 2026, meaning the drills were not conducted quarterly as required, which poses a potential safety risk to persons in care.

Based on observation, LPA observed the gate from the pool going east to the garden to be bolted shut and also a bolt placed, but not locked, on the sliding door from the covered patio, which poses an immediate safety risk to persons in care. CIVIL PENALTY ASSESSED.

Based on documents, the physician's reports for R1, R2, and R3 are on the old form and do not include required information, including behavioral expressions, which poses a potential safety risk to persons in care.

Based on documents, the physician's reports for R1 and R2 are more than a year old and there is no documentation of an annual routine visit within the past year in their files, which poses a potential health risk to persons in care.

Based on documents, S3 has not completed any hours of continuing medication training since January 2025, which poses a potential safety risk to persons in care.

Based on documents and admission, R1 is being given supplements including calcium with no doctor's orders on file and is not being given medications including Acetaminophen without discontinuation orders and R2 was not given their iron and vitamin C supplements after December 2024 despite the doctor's order not being discontinued, which poses a potential health risk to persons in care.

Based on documents, the licensee did not ensure S1's staff file contained documented evidence of the required 20-hour annual training, which poses a potential safety risk to persons in care.

Based on observation and documents, the licensee did not ensure the two fire extinguishers were certified yearly when they were last serviced on 03/14/23, which poses a potential safety risk to persons in care.

Based on observation, the licensee did not ensure supplements were secured in the non-lockable staff bedroom and sharps and toxins were secured in the kitchen where the key to the padlocks could not be located during the inspection, which poses an immediate safety risk to persons in care.

Based on observation, the licensee has been using a full bedrail on the bed of R1 who is not on hospice and could not locate doctors' orders for half bedrails for all 4 residents who are using half bedrails, which poses an immediate personal rights risk to persons in care.

Based on observation, the facility has two stories but does not have an evacuation chair, which poses a potential safety risk to persons in care.

Based on documents, no one present or associated with the facility has a valid administrator's certificate, which poses a potential safety risk to persons in care.