Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87412(a)
- Regulation authority
- CCR
What the official deficiency says
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain 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 two (02) out of two (02) staff with incomplete files which poses/posed a potential health, safety or personal rights risk to persons in care
Official plan of correction
POC Due Date: 08/30/2025 Plan of Correction Licensee to obtain health screening, criminal record statement, personnel record, and CPR certification, acquire necessary signatures, and maintain complete records for all staff. Licensee will submit proof of correction by the POC due date.
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 six (06) out of six (06) residents with incomplete files which poses/posed a potential health, safety or personal rights risk to persons in care
Official plan of correction
POC Due Date: 08/30/2025 Plan of Correction Licensee to provide residents with consent forms, personal rights forms, and all other missing files, acquire necessary signatures, and maintain complete records for all residents. Licensee will submit proof of correction by the POC due date.
Facility condition and maintenanceType B
- Official classification
- Type B
- Official code
- 87303(e)(4)
- Regulation authority
- CCR
What the official deficiency says
87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (4) Grab bars shall be maintained for each toilet; bathtub and shower used by residents. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above in one (01) out of two (02) toilets not having grab bars which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/30/2025 Plan of Correction Licensee to acquire grab bars through a commode or new installation and provide a photograph of the correction by the POC due date.
Health conditions and treatmentsType A
- Official classification
- Type A
- Official code
- 87608(a)(5)(B)
- Regulation authority
- CCR
What the official deficiency says
87608 Postural Supports (a) Based on the individual's preadmission appraisal... Postural supports may be used under the following conditions. (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above in one (01) out of six (06) residents using full bed rails without a prescription or hospice services which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/21/2025 Plan of Correction Licensee to discuss the issue with the resident's family and determine whether half bed rails will be used or to assist the resident in obatining hospice services. Licensee to remove the full bed rails in the meantime.