SHILOH RETREAT

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement is not met as evidenced by: Based on interviews and record review, R1 left the facility unassisted which poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee shall conduct an in-service training to ensure staff are providing supervision to residents. ***The inservice log was received during the visit today. POC will be cleared.

Deadline recorded: Jun 3, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.69(e)(3)

Regulation authority

HSC

What the official deficiency says

(e) Each person who provides employee training under this section shall meet the following education and experience requirements: (3) The licensed residential care facility for the elderly shall maintain the following documentation on each person who provides employee training under this section: 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 due to four (4) of (4) staff files did not show documented staff training (staff attending training, topics, hours and dates) which poses/posed a potential health, safety or personal rights risks to persons in care.

Official plan of correction

POC Due Date: 12/15/2025 Plan of Correction House Manager will create training logs with staff names (signatures), topics, hours and dates of training by POC date.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records..(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Based on interviews, records review, the Administrator did not comply with the section cited above in which the staff failed to sign the Medication Administration Record (MAR) on the correct date, and omissions in signing the MAR altogether for R1-R2 which poses a potential health, safety or personal rights risk to residents in care.

Official plan of correction

** This report supersedes the original complaint investigation report dated 8/21/2025 to change the deficiency for Section 87506 from Type A to Type B, findings remain the same.” Administrator shall provide in-service training to all staff on how to properly document the Medication Administration Record (MAR), as well as develop a policy requiring that (2) people verify medication records. Administrator to send a copy of the training log, along with the topics covered, and a sign-in sheet of staff who participated to CCL/LPA by POC due date.

Deadline recorded: Sep 9, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can 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: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Based on interview, records review, the Administrator did not comply with the section cited above in which staff missed medications in the blister packs and medications that were dropped and replaced with doses from the following day's blister pack without proper documentation for R1-R2 which poses an immediate health, safety or personal rights risk to residents in care.

Official plan of correction

Administrator shall conduct an In-Service Training to all staff on appropriate Medication Dispensing Procedures. Administrator to provide/submit a copy of the training log along with the topics discussed, and the sign in sheet of staff name who attended with the date to CCL/LPA by POC due date.

Deadline recorded: Aug 22, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records..(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Based on interviews, records review, the Administrator did not comply with the section cited above in which the staff failed to sign the Medication Administration Record (MAR) on the correct date, and omissions in signing the MAR altogether for R1-R2 which poses an immediate health, safety or personal rights risk to residents in care.

Official plan of correction

Administrator shall conduct an In-Service Training to all staff on proper documentation of Medication Administration Record (MAR) and develop a policy to have (2) person verification of medication records. Administrator to provide a copy of the training log along with the topics discussed, and the sign in sheet of staff name who attended with the date to CCL/LPA by POC due date.

Deadline recorded: Aug 22, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care..(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: Based on interviews, records review, the Administrator did not comply with the section cited above in which there were instances of pre-pouring medications prior to administration for R1-R2 which poses an immediate health, safety or personal rights risk to residents in care

Official plan of correction

Administrator agreed to provide in-service medication training to all staff that assist with preparing and administering medications. A copy of the training materials, scheduled date of training and list of participants to be sent to LPA by POC due date.

Deadline recorded: Aug 22, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements..(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by: Administrator did not comply with the section cited above in which the Administrator did not submit an incident report regarding multiple medication administration discrepancies for R1-R2 which poses a potential health, safety or personal rights risk to residents in care.

Official plan of correction

Administrator will conduct an in-service training to all staff regarding Reporting Requirements and sign in sheet of the training. Administrator will also send a self-certification indicating that he read, reviewed and understood Title 22 Regulations, Section 87211. Administrator to submit copy of the In service training and self certification to CCL/LPA by POC due date.

Deadline recorded: Aug 27, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.652(c)

Regulation authority

HSC

What the official deficiency says

Admission Agreements 1569.652 Refund conditions.(c)A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued...to entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed. This requirement not met as evidence by: Based on interviews and record review, licensee failed to refundR1's monies with 15 days after R1's belonging were removed and after R1's death.

Official plan of correction

Licensee to produce proof of entire prorated refund by 04/25/2025.

Deadline recorded: Apr 14, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility...: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on interviews and documents reviewed licensee did not ensure R1 was provided medical care in a timely manner after developing a Stage 4 pressure wound which poses an immediate risk to the persons health, safety, or personal rights of the persons in care.

Official plan of correction

Administrator will schedule training for staff on procedures, notifying responsible parties, and seeking medical care upon observing wounds in residents by POC due date 12/17/24, and will submit a copy of log, training description and duration of training by 12/31/24. ***An immediate Civil Penalty of $500.00 is being issued today, due to resident sustaining wound while in care. Refer to LIC 421IM*

Deadline recorded: Dec 17, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87633(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (1) The licensee has received a hospice care waiver from the department. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview, the licensee did not comply with the section cited above in [count] out of 2 out of 5 clients, because the facility currently has a hospice waiver approved for 2 residents, however there are currently 4 residents whoare on hospice, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/07/2024 Plan of Correction Administrator is to ensure that the facility has an approved hospice waiver for the appropriate number of residents at all times. Administrator is to email a Hospice Waiver increase request letter to the LPA by the POC due date.