Hazardous items and storageType A
- 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 observation, the licensee did not comply with the section cited above. Laundry detergent was accessible in the laundry room and paint containers were accessible in the garage area which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/15/2025 Plan of Correction Per discussion, administrator will provide training to staff. Proof of training will be submitted to the Department by POC due date.
Medication handling and storageType A
- Official classification
- Type A
- Official code
- 87465(h)(2)
- Regulation authority
- CCR
What the official deficiency says
(h) The following requirements shall apply to medications which are centrally stored: (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: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. Medication closet was observed to be unlocked during this visit. Additionally, medications were observed in resident bathroom and inside the garage refrigerator and are accessible to residents. These poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/15/2025 Plan of Correction Per discussion, administrator will obtain a locked box for the medications that require refrigerator. Per discussioin, administrator will retrain staff regarding the regulation cited above. Proof of training will be submitted to the Department by POC due date.
Facility condition and maintenanceType B
- Official classification
- Type B
- Official code
- 87303(a)
- Regulation authority
- CCR
What the official deficiency says
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation the licensee did not comply with the section cited above. 1 of 2 exit gates was observed to be missting a self-latching lock which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/21/2025 Plan of Correction Per discussion, Administrator will submit a photo of the repaired gate to the Department by POC due date.
Medical and dental careType B
- Official classification
- Type B
- Official code
- 87465(d)(3)
- Regulation authority
- CCR
What the official deficiency says
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to 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: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review and interview, the licensee did not comply with the section cited above. Facility do not document PRN medication administration which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/21/2025 Plan of Correction Per discussion, administrator will submit a letter of acknowledgement of the cited regulation and will state they will start documenting PRN medication administration. Submit letter by POC due date.