Follow-up on corrections·November 6, 2025

Citations

6 citations recorded^*CCLD

• 87211(a)(1)(D)Type B

  87211 Reporting Requirements (a) Each licensee ... (1) A written report shall be submitted to the licensing agency and to the person responsible....(D) Any incident which threatens the welfare, safety or health of any resident ... This requirement was not met as evidenced by staff not reporting when R1 had a wound to authorized representatives, this poses an immediate health and safety risk to residents in care.

• 87464(c)Type A

  87464 Basic Services (c)... basic services are desired and/or needed ... provided for, each resident...This requirement was not met as evidenced by records review and interviews. Based on records review and interviews, staff used two diapers on R1 instead of doing more frequent changing. "Double diapering" is a practice that can cause pressure injuries. Staff was told to discontinued double diapering but still continued to do so on more than one occasion. This poses an immediate health and safety risk to residents in care.

• 87465(a)(1)Type B

  Arrange appropriate medical and dental care

  87465 Incidental Medical and Dental Care (a) A plan for incidental medical .... routine medical ... care ...(1) ...l arrange, or assist in arranging, for medical ... care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by record review and interviews that corroborate staff did not implement preventative measures or follow care instructions provided by Hospice staff, which resulted in the resident developing pressure injuries while in care. This poses a potential or immediate health risk to residents in care.

• 87468.1(a)(2)Type B

  Safe, healthful, comfortable accommodations

  87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by record review and interviews confirming resident 1 (R1) developed bruises and skin tears however Facility staff was unable to provide an explanation or documentation of all incidents; It was the hospice company who was mostly communicating incidents to responsible persons. Additionally, staff did not ensure all of R1's personal belongings were transferred to the facility upon relocation on 9/5/25. This poses a potential or immediate health risk to residents in care.

• 87405(a)Type B

  Certified administrator requirements and substitute coverage

  87405 Administrator - Qualifications and Duties (a) .... When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility... This requirement was not met as evidenced by LIC 308 listing two individuals whom are no longer staff at the facility. S1 and S2 stated administrator was out of the country during this visit but available to staff via phone call for any staff or resdeint needs.

• 87465(d)(3)Type A

  Record dose details and resident medication response

  87465 Incidental Medical and Dental Care (d)... for a prescription or nonprescription PRN medication. .. facility staff designated by the licensee, shall ... assist the resident with self-administration ...(3) The date and time ... medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the This requirement was not met as evidenced by records review and interviews: review of medication administration record (MAR) dated September 2025 revealed that staff signed for medications as given prior to the actual administration. Additionally, S2 did not complete the MAR on 11/6/25 immediately after administering the medications to residents in care. Interview with staff confirmed that they pre-sign MARs to "save time". The practice constitute inaccurate medication documentation and fails to ensure that medication records reflect the actual time and date of administration, as required by Title 22. This poses an immediate health and safety risk to residents in care, as medications may be missed, duplicated, or administered incorrectly

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