Follow-up on corrections·February 12, 2026

Citations

4 citations recorded^*CCLD

• 87465(g)Type A

  Call 9-1-1 for imminent health threats

  87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis...This requirement has not been met as evidence by: Based on interviews conducted with facility staff and records reviews of fire department service calls, the facility staff failed to seek medical attention after observing R1’s significant change of condition at 7:30am, which poses an immediate risk to the health and safety of the residents in care.

• 87211(a)(2)Type B

  Report serious outbreaks and major accidents

  87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports.: (2) Occurrences, such as...major accidents which threaten the welfare, safety or health of residents..., shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement was not met as evidence by: Based on LPA’s records review and interviews with the Licensee, the facility failed to notify the Department about R1’s hospitalization on 9/10/25 and R1’s death on 10/31/25, which could pose a potential risk to the health and safety of residents in care.

• 87463Type B

  87463 Reappraisals (i) When there is significant change in condition, ...or once every 12 months, whichever occurs first, the licensee shall arrange an in-person or virtual meeting or conference call to share the reappraisal with the resident, the resident's representative, if applicable, and appropriate facility staff...This requirement was not met as evidence by: Based on LPA’s records review and interviews with the Licensee, the Licensee failed to update R1’s care after they had a significant change of condition, which poses a potential risk to the health and safety of the residents.

• 87466Type B

  Regular observation and documentation of resident changes

  87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental..., the licensee shall ensure that such changes are documented & brought to the attention of the resident's physician and the resident's responsible person, This requirement has not been met as evidence by: Based on LPA’s records review and interviews with the Licensee, LPA learned that Licensee failed to obtain an updated physician’s report (LIC602) for R1 after they have a significant change of condition and ambulatory status, which poses a potential risk to the health and safety of the residents in care.