Hazardous items and storageType B
- Official classification
- Type B
- 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, cleaning chemicals were stored in an unlocked cabinet next to the kitchen refrigerator which poses a potential health, safety risk to persons in care.
Official plan of correction
POC Due Date: 11/26/2025 Plan of Correction AD stated in-service training will be completed with all staff at the facility. Chemical were removed from the cabinet during LPA visit. AD to submit proof of training to LPA by POC due date.
Fire safety and emergency preparednessType B
- 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 record review, there is no documented evidence of disaster drills completed within the last quarter which poses a potential health and safety risk to persons in care.
Official plan of correction
POC Due Date: 11/26/2025 Plan of Correction AD stated drills have been completed but not documented. AD to document and send proof to LPA by POC due date.
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87411(f)
- Regulation authority
- CCR
What the official deficiency says
87411(f) Personnel Requirements - General All personnel...shall be in good health...Good physical health shall be verified by a health screening , including x-ray or an intradermal test, performed by a physician... This requirement is not met as evidenced by: Deficient Practice Statement Based on record review one out of two staff did not have documented evidence of TB testing results which poses a potential health and safety risk to persons in care.
Official plan of correction
POC Due Date: 11/26/2025 Plan of Correction AD stated two out two staff member present will retake TB testing. AD will provide proof to LPA by POC due date.