Routine inspection·October 7, 2025

Citations

5 citations recorded^*CCLD

• 1569.696Type B

  HEALTH & SAFETY CODEAll RCFEs shall provide training to direct care staff on postural supports, restricted conditions or health services, & hospice care...training shall include all of the following: 4 hours of training on the care, supervision, and special needs of those residents, prior to providing direct care to residents... This requirement is not met, as there is no evidence that staff received training on restricted health conditions, which poses a potential health, safety or personal rights risk to clients i care.

• 87411(f)Type B

  Health screening and fitness requirements

  PERSONNEL REQUIREMENTS--GENLAll personnel...shall be in good health, & physically & mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than 6 months prior to or 7 days after employment or licensure. A report shall be made of each screening, signed by the examining physician. This requirement is not met, as there is no TB test result for Staff #3 & #4 & no health screening for staff #4.

• 87463(h)Type B

  Annual routine visit with medical professional

  REAPPRAISALSThe licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every 12 months, either in person or by video appointment. Documentation of the annual routine visit, such as a visit summary, shall be added to the resident's record. record. This requirement is ot met, as MD reports for clients #2 and #4 are dated more than 12 months ago. Licensee failed to ensre that annual routine medical evaluations are documented, which poses a potential health, safety or personal rights risk to clients in care.

• 87468.1(a)(6)Type A

  Freedom to leave and not be locked in

  PERSONAL RIGHTSResidents have the personal right..to leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This requirement is not met, as glass sliding glass door in room #1 is secured with a screw & wood stick so client cannot access the door to exit.Side yard gate on south side is padlocked.Licensee failed to ensure that exits are accessible to clients, which poses an immediate health, safety or personal rights risk to clients in care.

• 87468(a)Type B

  REAPPRAISALSThe pre-admission appraisal...shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first.... and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met, as appraisals for clients #2, #3, #4 are dated more than 12 months ago. Licensee failed to ensure that appraisals are updated annually.