Follow-up on corrections·April 22, 2026

Citations

12 citations recorded^*CCLD

• 87303(a)Type B

  Maintain facility in clean, safe, sanitary condition

  87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on observations, interviews conducted, and records reviewed, the facility did not ensure that premises was free from pests, including multiple bedrooms for residents, which poses a potential health, safety, and personal rights risk to residents in care.

• 87405(a)Type B

  Certified administrator requirements and substitute coverage

• 87555(b)(7)Type B

  Modified diets for medical necessity

  87555 General Food Service Requirements (b) The following food service requirements shall apply: (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement is not met as evidenced by: Based on observations, interviews conducted, and records reviewed, the facility did not ensure that R1 was provided food belonging to their medically prescribed modified diet, which poses a potential health, safety, and personal rights risk to residents in care.

• 87465(h)(5)Type A

  Keep prescriptions in original containers

  87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: Based on interviews conducted and observations, the facility did not ensure that residents' medications were kept in a safe and locked place, which poses an immediate health, safety, and personal rights risk to the residents in care.

• 87465(h)(6)Type A

  Record centrally stored prescriptions and refill data

  87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year (...). This requirement is not met as evidenced by: Based on LPA's observations and records reviewed, the facility did not ensure to maintain a record of centrally stored medications for each resident for at least one (1) year, which poses an immediate health, safety, and personal rights risk to the residents in care.

• 87628(a)Type B

  Allowing diabetic residents based on self-management ability

  87628 Diabetes (a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional. This requirement is not met as evidenced by: Based on LPA's observations, interviews conducted, and records reviewed, the facility did not ensure resident admitted was assessed to be able to perform their own glucose testing, which poses a potential health, safety, and personal rights risk to the residents in care.

• 87506(a)Type B

  Maintain separate complete record for each resident

• 87465(h)(2)Type A

  Store centrally held medications in locked secure place

  87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Based on interviews conducted and observations, the facility did not ensure that residents' medications were kept in a safe and locked place, which poses an immediate health, safety, and personal rights risk to the residents in care.

• 1569.625(b)(1)Type B
• 87411(a)Type B

  Facility personnel sufficiency and competence

• 87411(d)Type B

  On-the-job training requirements

• 87507(h)(4)Type B