Follow-up on corrections·January 22, 2026

Citations

10 citations recorded^*CCLD

• 87465(e)Type A

  Require physician order and label for PRN medication

  Incidental Medical and Dental Care (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. This requirement was not met based on records and statements that found R1's medications were not administered as ordered.This posed an immediate risk to resident.

• 87470(a)(4)(C)Type B

  Infection Control Requirements (a)(4)(C) Gloves shall be removed and discarded in the nearest appropriate waste receptacle with a tight-fitting cover immediately following the glove use as required.This requirement was not met based on observations and interviews. This posed an potential risk to residents health and safety.

• 87468.2(a)(4)Type A

  Right to sufficient care and qualified staff

  Additional Personal Rights of Residents in Privately Operated Facilities (a) (4) 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 was not met based on video and statements that found S1 did not provide appropriate transfer request to R1. This posed and immediate risk to R1.

• 87411(c)Type B

  Staff training in personal care activities

  Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training… This requirement was not met based on records review and interview finding no recorded training for S1 or S2. This posed a potential risk to residents.

• 87307(a)(3)(4)Type B

  87307 Personal Accommodations and Services (a)(3)(F) Basic laundry service… This requirement was not met based on statements that resident personal belongings were not kept separate from others and that R1’s personal linens were not properly laundered. This posed a potential risk to resident.

• 87465(h)(6)Type B

  Record centrally stored prescriptions and refill data

  Incidental Medical and Dental Care (h)(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. There was not a recording of R1 skin treatment in the centrally stored medication record.

• 87211(a)Type B

  Licensee reports required by licensing agency

  Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require. This requirement was not met based on interviews that Administrator failed to report incidents identified. This posed a potential risk to residents.

• 87555(b)(8)Type B

  Food quality controls and rejected damaged goods

  General Food Service Requirements (b)(8) All food shall be of good quality… Food in damaged containers shall not be accepted, used or retained. This requirement was not met based on observation. This posed a potential risk to residents.

• 87355(c)Type A

  Criminal Record Clearance (c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility… This requirement was not met based on records review and interview that found S1 and S2 did not have verified clearance prior to living and working at the home 5/27/25- 5/28-25.

• 87405(d)(2)Type B

  Conformance with applicable laws and regulations

  Administrator - Qualifications and Duties (d) (2) Knowledge of and ability toconform to the applicable laws, rules and regulations. Administrator failed to hiring, train, seek criminal record clearance of S1 and S2, meet reporting requirements, ensure fire safety, create initiate resident behavior plans, ensure infection control and to have been arguing with family in the presence of residents. This posed a potential risk to residents.