Hazardous items and storageType A
- Official classification
- Type A
- Official code
- 87309(a)
- Regulation authority
- CCR
What the official deficiency says
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in havingdangerous items accesible which poses an immediate safety risk to persons in care.
Official plan of correction
POC Due Date: 07/30/2025 Plan of Correction Dangerous items locked away POC clear
Medication handling and storageType A
- Official classification
- Type A
- Official code
- 87465(h)(2)
- Regulation authority
- CCR
What the official deficiency says
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in having unlocked medications which poses an immediate safety risk to persons in care.
Official plan of correction
POC Due Date: 07/30/2025 Plan of Correction Medications locked away POC clear
Licensing and administrationType B
- Official classification
- Type B
- Official code
- 1569.618(c)(3)
- Regulation authority
- HSC
What the official deficiency says
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 4 out of 4 staff not having CPR or First Aid which poses a potential safety risk to persons in care.
Official plan of correction
POC Due Date: 08/16/2025 Plan of Correction By POC facility agrees to get updated training for CPR/ First aid for all staff and notify CCLD
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87412(c)
- Regulation authority
- CCR
What the official deficiency says
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 3 out of4 staff not having any updated training which poses a potential personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/16/2025 Plan of Correction By POC facility agrees to get enroll all staff in required training and notify CCLD
Medical and dental careType B
- Official classification
- Type B
- Official code
- 87465(d)
- Regulation authority
- CCR
What the official deficiency says
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review the facility did not comply with the section above by having an inaccurate MAR which poses a potential health and safety violation for residents in care.
Official plan of correction
POC Due Date: 08/16/2025 Plan of Correction By POC Facility agrees to update and maintain the MAR as well as provide additional training to staff and notify CCLD.
Records and plan of operationType B
- Official classification
- Type B
- Official code
- 87506(b)
- Regulation authority
- CCR
What the official deficiency says
(b) Each resident's record shall contain at least the following information: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 6 out of 6 residents having incomplete or missing files which poses a potential personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/16/2025 Plan of Correction By POC Facility agrees to update residents files and notify CCLD.
Fire safety and emergency preparednessType B
- Official classification
- Type B
- Official code
- 1569.695(c)
- Regulation authority
- HSC
What the official deficiency says
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in not conducting quarterly emergency drills which poses a potential safety risk to persons in care.
Official plan of correction
POC Due Date: 08/16/2025 Plan of Correction By POC facility agrees to conduct drills and notify CCLD
Administrator qualificationsType B
- Official classification
- Type B
- Official code
- 87405(a)
- Regulation authority
- CCR
What the official deficiency says
a)All facilities shall have a qualified and currently certified administrator...to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in having a qualified Administrator which poses a personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/16/2025 Plan of Correction By POC Licensee agrees to designate a new Administrator and notify CCLD