BRITTA CARE

Official classification

Type A

Official code

87204(b)

Regulation authority

CCR

What the official deficiency says

(b) Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents. Residents whose condition becomes nonambulatory shall not remain in rooms restricted to ambulatory residents. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation and facility sketch review the licensee did not comply with the section cited above in one of five residents which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 08/13/2026 Plan of Correction AD will move non-ambulatory resident from bedroom #1 to bedroom #5; which is a non-ambulatory room.

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 LPA observation the licensee did not comply with the section cited above in five of five residents which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 08/13/2026 Plan of Correction Staff immediately located the key to lock the knives drawer.

Official classification

Type A

Official code

87309(c)

Regulation authority

CCR

What the official deficiency says

(c) Except as specified in subsection (d), the licensee shall implement reasonable interventions in order to ensure that nutritional supplements, vitamins, alcohol, cigarettes and other potentially toxic substances, such as certain plants, gardening supplies, and auto supplies, are stored so as not to pose a hazard to residents. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observation the licensee did not comply with the section cited above in one of five residents which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 08/13/2026 Plan of Correction Staff immediately removed the pre-poured medications for one of five residents into the secured drawer.

Official classification

Type A

Official code

87458(c)(1)(A)

Regulation authority

CCR

What the official deficiency says

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA interview and record review the licensee did not comply with the section cited above in one of five resident files which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 08/13/2026 Plan of Correction AD to obtain TB documentation for one of five residents and email paperwork to LPA by end of business 8/13/2026.

Official classification

Type A

Official code

1569.695(a)

Regulation authority

HSC

What the official deficiency says

(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observation and record review, the licensee did not comply with the section cited above in five of five residents in care which poses an immediate health, safety and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/13/2026 Plan of Correction AD will complete LIC 610E and email LPA by end of business 8/13/2026.

Official classification

Type A

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 LPA interviews and record review, the licensee did not comply with the section cited above in five of five residents which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 08/13/2026 Plan of Correction AD will provide a quarterly fire drill training and submit signed documentation of all participants, the date and review the LIC 610E via email to LPA by end of business 8/13/2026.

Official classification

Type B

Official code

87507(e)(2)

Regulation authority

CCR

What the official deficiency says

(2) The licensee shall conspicuously post in a location accessible to public view in the facility a complete copy of the approved admission agreement, modifications and attachments, or notice of their availability from the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation and intervew the licensee did not comply with the section cited above for five of five residents in care which poses a potential health, safety and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/11/2026 Plan of Correction AD will post a facility approved Admissions Agreement in a public common area by POC due date.

Official classification

Type B

Official code

87412(a)(11)

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: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observation, interview and file review, the licensee did not comply with the section cited above in one of five staff which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 09/11/2026 Plan of Correction AD obtain a LIC 503 Health Screening Report and TB for one of five staff members

Official classification

Type B

Official code

87412(a)(13)(B)

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: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e). 1. For Certified Administrators, a copy their current and valid Administrative Certification meets this requirement. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's record review, the licensee did not comply with the section cited above in one of five staff files which poses a potential personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/11/2026 Plan of Correction AD has completed CEUs and will continue to work with ACB to obtain a current Administrator's Certificate by POC due date.

Official classification

Type B

Official code

87411(d)

Regulation authority

CCR

What the official deficiency says

(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA interviews and file review the licensee did not comply with the section cited above in five of five staff members which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/11/2026 Plan of Correction AD will continue to have staff do online trarining and will document annual trainings. AD will email LPA completed trainings by 9/11/2026.

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 LPA interviews and file review the licensee did not comply with the section cited above in five of five staff files which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/11/2026 Plan of Correction AD will continue to have staff complete training and print certificates in staff files by POC due date.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA interviews and record review, the licensee did not comply with the section cited above in five of five staff members which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/11/2026 Plan of Correction AD will continue to provide staff trainings and will document for each staff member's file.

Official classification

Type B

Official code

87468(b)

Regulation authority

CCR

What the official deficiency says

(b) At the time the admission agreement is signed, a resident and the resident's representative shall be personally advised of and given a copy of: This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA file review, the licensee did not comply with the section cited above in three of five residents which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/11/2026 Plan of Correction AD will look for signed Admissions Agreements or complete new ones for three of five residents. AD will email LPA by POC due date with the required documents.

Official classification

Type B

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observations, record review and interviews, the licensee did not comply with the section cited above in five of five residents which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/11/2026 Plan of Correction AD will reconcile medication lists per physican's orders for the resident files by POC due date.

Official classification

Type B

Official code

87506(b)(15)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's interviews and file review, the licensee did not comply with the section cited above in three of five residents which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/11/2026 Plan of Correction AD will complete resident appraisals for three of five residents by POC due date.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's file review and interview the licensee did not comply with the section cited above in two of five residents which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/11/2026 Plan of Correction AD will complete resident appraisals by POC due daye.

Official classification

Type B

Official code

87705(b)(1)(A)

Regulation authority

CCR

What the official deficiency says

(b) Licensees shall be responsible for the following: (1) Ensuring staff receive the following training as part of the training requirements specified in Section 87208 Plan of Operation: (A) Dementia care, including, but not limited to, knowledge about hydration, nutrition, skin care, communication, therapeutic activities, behavioral challenges, the environment, and assisting with activities of daily living; This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's interviews and file review, the licensee did not comply with the section cited above in five of five staff which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/11/2026 Plan of Correction AD will continue to provide ongoing dementia training to five of five staff. AD will email LPA documentation by 9/11/2026.

Official classification

Type A

Official code

1569.605

Regulation authority

HSC

What the official deficiency says

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/31/2025 Plan of Correction Admin stated that proof of liability insurance will be submitted to LPA by POC due date.

Official classification

Type A

Official code

87412(a)(11)

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: (11) A health screening as specified in Section 87411, Personnel Requirements - General. 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 one of three staff, R3, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/31/2025 Plan of Correction Admin stated that proof of health screening will be submitted to LPA by POC due date.

Official classification

Type A

Official code

87355(e)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: 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 two out of three staff, R2 and R3, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/31/2025 Plan of Correction Admin stated that proof of fingerprint clearance receipts, and a written Acknowledge of Understanding of the said deficiency will be submitted to LPA by POC due date.

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 interview and record review, the licensee did not comply with the section cited above in three out of four staff, R2-R4 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/07/2025 Plan of Correction Admin stated that proof of CPR/first aid certificates for R2-R4 will be submitted to LPA on or before POC due date.

Official classification

Type B

Official code

1569.625(b)(1)

Regulation authority

HSC

What the official deficiency says

(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above in review of two out of two personnel files which R2 and R3 did not meet their 40 hour trianing which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/02/2026 Plan of Correction Administrator that proof of 40 hour training for R2 and R3 will be submitted to LPA by POC due date.

Official classification

Type B

Official code

87458(c)(1)

Regulation authority

CCR

What the official deficiency says

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: 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 three out of six residents, R2, R4, and R5, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/07/2025 Plan of Correction Administrator stated that proof of medical assessments (LIC602s) and TB test results for R2, R4, and R5 will be submitted to LPA by POC due date.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by: Deficient Practice Statement Based on file review, the licensee did not comply with the section cited above in six out of six residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/31/2025 Plan of Correction Administrator stated that proof of reappraisals and care plans for all residents will be submitted to LPA by POC due date.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions , and hospice care as required by subdivision (a) of Section 1569.696. This requirement is not met as evidenced by: Based on interviews and record review, Staff 1 (S1) and (S2) have not completed the trainings. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee to email updated trainings for S1 and S2 by POC due date.

Deadline recorded: Oct 18, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87456(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal. 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 which poses an immediate health, safety or personal rights risk to persons in care. LPA observed that two of six resident records did not have a pre-admission appraisal and/or the pre-admission appraisal was blank.

Official plan of correction

POC Due Date: 09/17/2024 Plan of Correction Licensee to email a pre-admission agreement for both residents to LPA by POC due date.

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 which poses a potential health, safety or personal rights risk to persons in care. LPA observed that two of two staff have expired cardiopulmonary resuscitation (CPR) cards.

Official plan of correction

POC Due Date: 09/23/2024 Plan of Correction Licensee to provide valid CPR cards for two of two staff.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. 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 which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/23/2024 Plan of Correction Licensee to email updated trainings for Staff 1 (S1) and S2 by POC due date.

Official classification

Type B

Official code

87468(c)(2)(A)

Regulation authority

CCR

What the official deficiency says

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/23/2024 Plan of Correction Licensee to email LPA POC by POC due date.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interviews of Administrator and staff, the facility did not ensure one out of two staff was associated to the facility as required prior to employment which poses an immediate Health, Safety or Personal Rights risk to persons in care.

Official plan of correction

POC Due Date: 08/25/2022 Plan of Correction Licensee acknowledges and agrees to associate S2 and to forward proof of correction by POC due date.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the facility did not ensure that six out of six resident pill box organizers, staff medications, and bug sprays were locked and inaccessible to the residents which poses an immediate Health, Safety or Personal Rights risk to persons in care.

Official plan of correction

POC Due Date: 08/25/2022 Plan of Correction Licensee agrees to fully secure all medications and toxic solutions which was corrected during the visit. Facility to provide training to all staff handling medications and toxic substances. Proof of training shall be forwarded to LPA by POC due date.

Official classification

Type A

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. Facility does not have COVID precaution/policy posted at facility entrance or throughout facility. LPA was not screened at entrance, no sign in policy in place, visitors are not screened, no papertowels in bathrooms, and no hand washing guidelines posted in bathrooms. This poses a potential health and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/03/2021 Plan of Correction Administrator to post and follow COVID precaution/policy signage/screening at entrance to facility and throughout facility and forward proof to LPA by POC due date.

Official classification

Type A

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observation, the Administrator did not comply with the section cited above in that LPA Martinez observed full bedrails on bed of R1. Staff report R1 is not on hospice. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/02/2021 Plan of Correction Licensee to remove full bedrail and obtain physician order for half rails if need for R1 and submit proof of correction by 12/02/2021.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. LPA observed unsecured medications (2 bottles of Mucus Relief Chest and an Inhaler in R1's room.This poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 12/01/2021 Plan of Correction Staff removed medication from room and locked away. Administrator to conduct in-service training on section cited and submit proof to CCLD by close of business day of 12/10/2021

Official classification

Type B

Official code

87618(b)(3)(B)

Regulation authority

CCR

What the official deficiency says

Oxygen Administration, " No Smoking-Oxygen in Use " signs shall be posted in the appropriate areas. This requirement is not being met as evidenced by: This requirement is not met as evidenced by: Deficient Practice Statement During the visit, LPA observed R2 and R3 have Oxygen machines present in their room and there are no " Oxygen in Use " signs present on their door. This poses a potential risk to the health and safety of the residents in care.

Official plan of correction

POC Due Date: 12/02/2021 Plan of Correction Administrator to post an " Oxygen in Use " sign on the door of R2 and R3 and to train all staff on section cited. Proof of correction to be sent to LPA by POC due date.