Follow-up on corrections·September 15, 2025

Citations

4 citations recorded^*CCLD

• 87211(1)(A)Type B

  87211 Reporting Requirements(1)(A)(1) A written report shall be submitted to the licensing agency... (A) Death of any resident from any cause regardless of where the death occurred...This requirement was not met as evidenced by: Based upon record review, LPA did not observe a Death Report. The Administrator did not ensure that the death reporting requirements were followed which posed a potential health and safety risk to residents in care.

• 87465(h)(2)Type A

  Store centrally held medications in locked secure place

  Incidental Medical and Dental Care 87465(h)(2) The following requirements shall apply to medications: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible...This requirement was not met as evidenced by: Based upon observation, LPA requested to audit medications and observed the medications cabinet to be unlocked. The staff did not ensure that the centrailly stored medications were locked and inaccessible to residents, which poses an immediate health and safety risk to residents in care.

• 87506(a)Type B

  Maintain separate complete record for each resident

  87506 (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a centrally...This requirement was not met as evidenced by: Based upon a request to review records, LPA observed a few of the current resident files but not the requested file. The facility did not ensure that all residents files were available for review which posed a potential health and safety risk to residents in care.

• 87633(f)(1)Type A

  87633 Hospice Care of Terminally Ill Residents (f) The licensee shall maintain a record of all hospice-related training provided... (1) The record of each training session shall specify the names...This requirement was not met as evidenced by: Based upon record review, LPA did not observe staff training specifically related to hospice care. The facility did not ensure that staff were trained in hospice care which poses an immediate risk to the health and safety of residents in care.