Routine inspection (multi-day)·January 5, 2026

Citations

8 citations recorded^*CCLD

• 1569.695(f)(1)Type B

  EMERGENCY PLANSA facility shall have...the following in place: An evacuation chair at each stairwell, on or before July 1, 2019.This requirement is not met, as there are no evacuation chairs in 3 stairwells.Licensee failed to ensure that evacuation chairs are installed in each stairwell, which poses a potential health, safety or personal rights risk to clients in care.

• 87303(e)(2)Type A

  MAINTENANCE AND OPERATIONHot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F and not more than 120 degree F .This requirement is not met, as hot water temperature tested at 140 degrees in room 12 on 2nd floor. Licensee failed to ensure that hot water temperature is within range of 105 to 120 degrees F., which poses an immediate health and safety risk to clients in care. This deficiency was cited on 12/8/25, but not corrected.

• 87412(a)(1Type B

  PERSONNEL RECORDSThe licensee shall ensure that personnel records are maintained on... each employee. Each personnel record shall contain...Employee's full name, Social Security number, Date of employment, Written verification that the employee is at least 18 years of age, including...a copy of his/her birth certificate or driver's license, Home address and telephone number, Educational background, Past experience, including...former employers... position for which employed...health screening....REcords for staff #1 do not include job application and health screening

• 87463(a)Type B

  REAPPRAISALSThe pre-admission appraisal, as specified in Section 87457... shall be updated in writing as frequently as necessary or once every 12 months... to note significant changes in condition...and to keep the appraisal accurate. This requirement is not met, as appraisals for clients #2, #7, #9 are dated over 12 months ago. Licensee failed to ensure that written appraisals are updated annually, which poses a potential health safety or personal rights risk to clients in care.

• 87411(c)(1)Type B

  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 there is no evidence that staff #1 and #2 have current first-aid training, which poses a potential health, safety or personal rights risk to clients in care. Licensee failed to ensure that all caregivers have current first-aid training.

• 87463(h)(1)Type B

  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...shall be added to the resident's record. This requirement is not met, as MD reports for clients #2 and #9 are dated more than 12 months ago. Licensee failed to ensure that MD reports are completed annually, which poses a potential health, safety or personal rights risk to clients in care.

• 87507(a)(1)(A)Type B

  ADMISSION AGREEMENTSThe licensee shall complete an individual written admission agreement...text of the admission agreement, including any attachments and modifications, shall be printed in black type of not less than 12-point type size, on plain white paper. The print shall appear on one side of the paper only.This requirement is not met, as original signed admission agreement for client #9 is printed on both sides of paper, which poses a potential health, safety or personal rights risk to clients in care.

• 87608(a)(3)Type B

  POSTURAL SUPPORTSA written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met, as residents in rooms #2, #3, #7, #8, #9, #15, #17, #18, #19, #20 have half bed rails on beds, which poses a potential health, safety or personal rights risk to clients in care.

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