Routine inspection (multi-day)·August 5, 2025

Citations

10 citations recorded^*CCLD

• 1569.696(a)Type B

  HEALTH AND SAFETY CODEAll RCFEs shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. This requirement is not met, as training records are not available for review. Licensee failed to maintain documentation that staff have received this training, which poses a potential health, safety or personall rights risk. This was cited on 9/3/24 and not corrected, as staff #6 did not have proof of training on hospice care, restricted health conditions.

• 87411(f)Type B

  Health screening and fitness requirements

  PERSONNEL REQUIREMENTS... 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 6 out of 6 staff files were missing health screenings and TB test results. Licensee failed to ensure that health screenings are maintained for all staff, which poses a potential health, safety or personal rights risk. This was cited on 9/3/24 and not corrected.

• 87465(e)(1Type B

  INCIDENTAL MEDICAL CAREFor every Rx and non Rx medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain ...specific information. This requirement is not met, as MD orders are not maintained for C3 OTC Senna and C6 Senna Plus. Licensee failed to ensure that MD orders are maintained for OTC meds, which poses a potential health, safety or personal rights risk

• 87465(i)(1Type B

  INCIDENTAL MEDICAL CARERx medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician & documented in the resident’s record nor disposed of... shall be destroyed in the facility by the facility administrator & another adult who is not a resident. Both shall sign a record, to be retained for at least 3 years, which lists... specific information. This requirement is not met, as Rx meds for former client observed in kitchen cabinet, which poses a potential health, safety or personal rights risk.

• 87468.1(a)(1)Type A

  Dignity in personal relationships

  PERSONAL RIGHTSResidents in all RCFEs shall have... the ... personal right to be accorded safe, healthful &comfortable accommodations, furnishings & equipment. This requirement is not met, as client in room #5 is observed in bed with recliner chair and wheelchair placed next to bed, preventing her from getting out of bed. Licensee failed to ensure that clients are accorded safe & healthful accommodations, which poses an immediate health, safety or personal rights risk to clients in care.

• 87468.1(a)(13)Type B

  PERSONAL RIGHTSResidents in all RCFEs shall have the personal right to have access to individual storage space for private use. This requirement is not met, as facility records are stored in client room #4. Licensee failed to ensure that client's room is for client's personal use and not used by staff. This poses a potential health, safety or personal rights risk to clients in care.

• 1569.626(a)Type B

  HEALTH AND SAFETY CODERCFEs shall meet...training requirements, as described in Section 1569.625, for all direct care staff...12 hours of dementia care training, 6 of which...completed before...working independently with residents, and the remaining 6 hours of which shall be completed within the first 4 weeks of employment. This requirement is not met, as training records are not available for review. Licensee failed to maintain documentation that staff have received dementia training, which poses a potential health, safety or personall rights risk. This was cited on 9/3/24, as staff #6 did not have dementia training.

• 1569.69(a)Type B

  HEALTH AND SAFETY CODE...employee shall complete 10 hours of initial training...consist of 6 hours of hands-on shadowing training...prior to assisting with the self-administration of medications, & 4 hours of other training or instruction, as described in subdivision (f)...be completed within the first 2 weeks of employment. This requirement is not met, as training records are not available for review. Licensee failed to maintain documentation that staff have received medication training, which poses a potential health, safety or personal rights risk. This was cited on 9/3/24, as staff #6 did not have medication training.

• 87465(h)(1)(4)Type B

  INCIDENTAL MEDICAL CAREAll centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is not met, as staff write on RX labels. Licensee failed to ensure that staff do not write on Rx labels, which poses a potential health, safety or personal rights risk to clients in care.

• 87618(b)(1)(B)Type B

  OXYGEN ADMINISTRATION..."No Smoking-Oxygen in Use" signs shall be posted in the appropriate areas.This requirement was not met, as there were no oxygen in use signs posted on 7/31/25 during initial annual inspection, which poses a potential health, safety or personal rights risk.