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 as during tour LPA observed client bathroom in main bldg to have cleaning solutions/chemicals in an unlocked bathroom sink cabinet, additionally there were unlocked cleaning chemicals and roach spray in Room1, R2's physician report that states they cannot have access to cleaning chemicals or disinfectants, this poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/17/2026 Plan of Correction During visit Administrator removed cleaning solutions and roach spray from R2's room and stored in locked cabinet and locked the bathroom cabinet with cleaning solutions in main building. Administrator/Licensee to retrain all staff on how to ensure all items which could pose a danger to residents are kept inaccessible to residents in care. and email LPA a copy of the training log with participant signatures by 7/30/26
Medical and dental careType A
- Official classification
- Type A
- Official code
- 87465(a)(4)
- Regulation authority
- CCR
What the official deficiency says
(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as during medication review LPA observed that R7 is missing 1 PRN medication, which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/17/2026 Plan of Correction Administrator/Licensee to contact pharmacy and order medication on order for R7 and show proof of reorder and delivery date to LPA by 7/17/26. Additionally a staff training must be conducted on medication and how to properly assist residents with medication to avoid such errors. A copy of the training log with participant signatures must be emailed to LPA by 7/30/26
Basic services and supervisionType B
- Official classification
- Type B
- Official code
- 87219(e)
- Regulation authority
- CCR
What the official deficiency says
(e) In facilities licensed for sixteen (16) to forty-nine (49) persons, one staff member, designated by the administrator, shall have primary responsibility for the organization, conduct and evaluation of planned activities. This person shall have had at least six (6) month's experience in providing planned activities or have completed or be enrolled in an appropriate education or training program. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above as Administrator Stated that Staff #5 is the designated staff with the primary responsibility being to plan,prepare and conduct activities, however, after file review S5 does not have the proper training or education, which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/30/2026 Plan of Correction Administrator/Licensee to either designate a qualified staff to be responsible for planned activites or provide S5 with the appropriate education or training program to qualify them for this responsibility. Proof of either or must be emailed to LPA by POC due date.
Fire safety and emergency preparednessType B
- Official classification
- Type B
- Official code
- 1569.69(g)
- Regulation authority
- HSC
What the official deficiency says
(g) Residential care facilities for the elderly licensed to provide care for 16 or more persons shall maintain documentation that demonstrates that a consultant pharmacist or nurse has reviewed the facility’s medication management program and procedures at least twice a year. 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 as per administrator the Veterans Affairs calls facility to do the medication review at least 2 times a year, however, they do not have any documentation of the review, which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/30/2026 Plan of Correction Administrator to have a qualified pharmacist or nurse review facility's medication management and procedures and email a copy of the review to LPA by POC due date. (the pharmacist/nurse cannot be employed by facility or related to administrator/licensee as this creates a conflict of interest)
Medication handling and storageType B
- Official classification
- Type B
- Official code
- 87465(h)(4)
- Regulation authority
- CCR
What the official deficiency says
(h) The following requirements shall apply to medications which are centrally stored: (4) All 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 evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as during medication review LPA observed 2 Residents Medications that were missing labels R6 and R7 are prescribed with a routine vitamin and the bottles do not have labels, which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/30/2026 Plan of Correction Administrator/Licensee to contact pharmacy, obtain a copy of the label and place label on the medication, a photo of bottle with required label to be emailed to LPA by POC due date.
Medication handling and storageType B
- Official classification
- Type B
- Official code
- 87465(h)(5)
- Regulation authority
- CCR
What the official deficiency says
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as during medication review LPA observed trays with medication in small plastic cups, the medications (per administrator) are prepacked for the week in the small containers, which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/30/2026 Plan of Correction LPA expalined that medication cannot be transfered from its original container, Administrator to review the regulation in its entirety once reviewed they must fill out, sign and date the POC Form (LIC9098) provided during visit and email a copy to LPA by POC due date, additonally Administrator is to develop a plan on how they will ensure they will stay in compliance with the regulation, retrain staff and email a copy of plan and training log to LPA.