Routine inspection·January 20, 2026

Citations

6 citations recorded^*CCLD

• 87412(g)Type A

  Maintain personnel records at facility location

  PERSONNEL RECORDSAll personnel records shall be maintained at the facility and shall be available to the licensing agency for review. This requirement is not met, as there are no staff records available for review. Licensee failed to ensure that staff records are maintained at facility, which poses an immediate health, safety, or personal rights risk to clients in care.

• 87457(c)Type B

  Complete admission suitability appraisal

  PREADMISSION APPRAISALPrior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs. This requirement is not met, as there are no appraisals on file for all residents. Licensee failed to ensure that appraisals are maintained for all clients, with poses a potential health, safety or personal rights risk to clients in care.No preadmission appraisals for clients #3 and #4 and no appraisals for clients #1 and #2

• 87458(a)Type B

  Obtain baseline medical assessment before resident admission

  MEDICAL ASSESSMENTPrior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record. This requirement is not met, as there are no MD reports for clients #3 and #4. Licensee failed to ensrue that MD reports are maintained prior to admission and maintained, which poses a potential health, safety or personal rights risk to clients in care.

• 87465(h)(6)Type A

  Record centrally stored prescriptions and refill data

  INCIDENTAL MEDICAL CARE 87465A record of centrally stored prescription medications for each resident shall be maintained and include names of the resident for whom prescribed, prescribing physician and pharmacist, drug name, strength and quantity, dates filled, started & expiration, prescription number and instructions. This requirement is not met, as medications for 3 residents are not recorded on Centrally Stored Medications Records. Licensee failed to ensure that medications for clients are logged on CSMR, which poses a potential health or safety risk.

• 87608(a)(5)(B)Type A

  POSTURAL SUPPORTSBed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.This requirement is not met, as hospice client #2 has full bed rails, but this is not included in hospice care plan. Licensee failed to ensure that full bed rails are included in hospice care plan, which poses a potential health, safety or personal rights risk to clients in care.

• 87305(a)Type B

  Requirement for building permit before construction

  ALTERATIONS TO BUILDINGS/GROUNDSPrior to construction or alterations, all facilities shall obtain a building permit.This requirement is not met, as rear family room has been extended almost 8 feet, but there is no approved building permit. Licensee failed to maintain approved building permit, which poses a potential health, safety or personal rights risk to clients in care.