RDB GUEST HOME

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

(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: Based on observation, the Licensee did not comply with the section cited above as LPA observed medication requiring refrigeration to be accessible in the kitchen fridge.

Official plan of correction

Staff immediately took the medication and placed it in the staff refrigerator, which is inaccessible to residents and located in the garage. HM stated an in-service will be conducted to ensure centrally stored medicines are kept in a safe and locked place.

Deadline recorded: May 27, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

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. This requirement is not met as evidenced by: Based on observation and staff interview, the Licensee did not comply with the section cited above as HM was unable to provide any documentation pertaining to S1 and S1 stated they did not have a facility file, which poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

HM stated they will complete a personnel file for S1 and a copy will be provided to LPA via email by POC date.

Deadline recorded: May 27, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(a)

Regulation authority

CCR

What the official deficiency says

(a) Living accommodations...The facility shall be large enough to provide comfortable living accomodations and privacy for the residents, staff... This requirement is not met as evidenced by: Based on observation and staff interview, the Licensee did not comply with the section cited above as staff is currently residing in the garage, which poses a potential safety and personal rights risk to persons in care.

Official plan of correction

HM stated staff will no longer reside in the garage and all their personal belongings removed. HM stated video proof will be provided to LPA via email by POC date.

Deadline recorded: Jun 26, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(3)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. 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 one of two resident bathrooms which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/26/2025 Plan of Correction Staff will lower water heater temperature and will email or contact LPA with photo documentation that the main bathroom water temperature is between 105 to 120 degrees Fahrenheit. Staff will also post signage stating water temperature is currently over 125 degrees Fahrenheit.

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 one of two resident bathrooms which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/26/2025 Plan of Correction House Manager will immediately remove cleaning products and disinfectants and store in the locked cabinet beneath the kitchen sink.

Official classification

Type B

Official code

87457(c)

Regulation authority

CCR

What the official deficiency says

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA record review and interview the licensee did not comply with the section cited above in three of six resident records which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/08/2025 Plan of Correction Licensee (LE) will complete Pre-admissions and Appraisal and Needs Service Plans for three of six resident records by the Plan of Correction Date. LE will email documentation to LPA.

Official classification

Type B

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA record review and interview the licensee did not comply with the section cited above in three of six resident records which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/08/2025 Plan of Correction Licensee (LE) will obtain Medical Assessments for three of six resident records by the Plan of Correction Date. LE will email documentation to LPA.

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 LPA interview and record review, the licensee did not comply with the section cited above for six of six residents which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/08/2025 Plan of Correction Licensee (LE) will conduct a fire drill quarterly including documentation the type of fire drill performed and staff signatures showing participation. LE will email LPA by the Plan of Correction Date.

Official classification

Type B

Official code

87608(a)(5)(A)

Regulation authority

CCR

What the official deficiency says

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. 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 five of six residents which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/08/2025 Plan of Correction Licensee (LE) will obtain physician's orders for bed rails for five resident files. LE will email LPA by Plan of Correction Date with bed rail orders.

Official classification

Type B

Official code

87633(b)

Regulation authority

CCR

What the official deficiency says

(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include 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 1 out of 4 resident's did not have their hospice care plan at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/19/2024 Plan of Correction House Manager has agreed to read regulation entirely and send LPA a self-certified letter that the regulation 87633(b) was read and understood. The staff will send proof they have recicved the hospice care plan.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. 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 1 out of 4 record review did not have an updated medical assesment. R1 last medical assesment was conduct in 2022 as which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/19/2024 Plan of Correction House Manager has agreed to read regulation entirely and send LPA a self-certified letter that the regulation 87705(c)(5)(A) was read and understood. The staff will also send proof they have schedule a medical appointment for R1.