Post-licensing visit·February 27, 2026

Citations

5 citations recorded^*CCLD

• 1569.626Type B

  HEALTH AND SAFETY CODEAll RCFEs shall meet the following training requirements.... for all direct care staff: 12 hours of dementia care training, 6 of which shall be completed before a staff member begins working independently with residents...remaining 6 hours of which shall be completed within the first 4 weeks of employment. This requirement is not met, as staff #4 has been employed for over 4 weeks, and only received 5 hours of dementia training. Licensee failed to ensure that new staff received required dementia training, posing a potential risk to clients.

• 87307(a)Type B

  Living accommodations aligned with facility function

  PERSONAL ACCOMMODATIONS/SVCSLiving accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others... This requirement is not met, as sofa in living room is used by staff for sleeping at night. Licensee failed to ensure that common areas are reserved for common use, which poses a potential health, safety or personal rights risk to clients in care.

• 87355(c)Type A

  CRIMINAL RECORD CLEARANCE TRANSFERA licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another...by providing ...documents to the Department. This requirement is not met, as criminal record clearance for staff #2 is not yet associated to this facility. Licensee failed to ensure that all staff with client contact maintain criminal record clearance and association to facility, which poses an immediate health or safety risk to clients in care. Staff #2 started working 2/8/26.

• 87411(c)(1)Type B

  First aid training requirements

  PERSONNEL REQUIREMENTS GENERALStaff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.This requirement is not met, as staff #1 and #4 do not have proof of current first aid training, which poses a potential health, safety, or personal rights risk to clients in care.

• 87465(h)(6)Type B

  Record centrally stored prescriptions and refill data

  INCIDENTAL MEDICAL CAREA 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 6 Rx & OTC meds for client #2 are not recorded on Centrally Stored Medications REcords, and OTC Robitussin for client #1 is not logged. Licensee failed to ensure that there is a written record of all centrally stored client medications, which poses a potential risk.