Routine inspection (multi-day)·September 10, 2025

Citations

10 citations recorded^*CCLD

• 87465(a)(4)Type A

  Assist residents with self-administered medication

  Based on record review, licensee did not comply with the regulation cited above.(For the R3’s melatonin being given the wrong dosage)Based on record review, licensee did not comply with the regulation cited above. Since the 07/30/25 initial annual visit the Administrator has corrected the dosage of melatonin being dispensed R3.

• 87202(a)Type A

  Maintain fire clearance before retaining specified persons

  Based on observations, interviews and a review of records, the facility is not in compliance with the fire clearance as the rooms are being used differently that indicated on the sketch provided to the fire inspector. This facility is only cleared for two rooms for a 2 capacity each and two rooms cleared for 1 capacity each. This poses an immediate health, safety and personal rights risk to the residents in care.

• 87203Type A

  Maintain facilities for fire and panic safety

  Based on observation and interviews, the licensee did not comply with the section cited above. During physical observation on 9/10/25, LPAs observed the fire door to be propped open with a door stopper. Interview with staff on duty stated they keep this door open. This which poses/posed a immediate health, safety or personal rights risk to persons in care.

• 87211(a)(1)Type B

  Report specified resident events within seven days

  Based on record review, licensee did not comply with the regulation cited above.LPA Hayes observed during the initial annual visit that a missing person’s report was submitted for R4 during R4’s file review. This incident was not reported to the Department by the Admin/Licensee. This poses/posed an immediate health, safety or personal risk to persons in care.

• 87303(a)Type B

  Maintain facility in clean, safe, sanitary condition

  Based on observations on 7/30/25, LPAs observed the kitchen stove was in disrepair. This poses/posed a potential health, safety or personal rights risk to persons in care. LPAs observed a new stove in place of the old stove during today's visit.

• 87309(a)Type A

  Ensure hazardous items are locked and not unattended

  Based on observation, the licensee did not comply with the section cited above. During physical observation on 9/10/25, LPAs observed a fabric softener on a shelf inside the garage; additionally, the bin that staff use to keep laundry supplies is not locked. LPAs observed the door to the garage can be unlocked from the inside by residents in care. This poses/posed an immediate health, safety or personal rights risk to persons in care.

• 87465(a)(5)(A)Type A

  Authorized physician-prescribed self-administered meds

  Based on record review, licensee did not comply with the regulation cited above.(For R4's lack of prescription for melatonin)This poses/posed an immediate health, safety or personal rights risk to persons in care.

• 87465(h)(2)Type A

  Store centrally held medications in locked secure place

  Based on observation, the licensee did not comply with the section cited above. During physical observation on 9/10/25, LPAs observed a resident’s medication in a pill cup on top of a shelf at the medication area. This poses/posed an immediate health, safety or personal rights risk to persons in care.

• 87468.1(a)(3)Type A

  Protection from punishment and intimidation

  Based on observation on 7/30/25, LPA observed the kitchen refrigerator to be locked with a black cable lock and not accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care. LPAs did not observe a locked refrigerator at the time of visit on 09/10/25.

• 87705(f)Type A

  Requirements for locking exterior exits

  Based on observations on 9/10/25 and 7/30/25, LPAs observed the exit gate to be locked with a padlock. This poses/posed an immediate health, safety or personal rights risk to persons in care. The padlock was removed during today's visit.