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 LPA observations, the licensee did not comply with the section cited above by cleaning supplies were stored in an unlocked and left unattended in a non-private bathroom. which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 03/09/2026 Plan of Correction Corrections were made by staff removing the cleaning supplies and placing them in a locked area.
Medication handling and storageType B
- Official classification
- Type B
- Official code
- 87465(h)(4)
- Regulation authority
- CCR
What the official deficiency says
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observations, the licensee did not comply with the section cited above by staff altering prescription labels on two of resident#1's medictions; which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 03/19/2026 Plan of Correction The Licensee/Administrator shall retrain staff and provide inservice on medication management and provide documentation of training to the Licensing Division by POC due date.
Medication handling and storageType B
- Official classification
- Type B
- Official code
- 87465(h)(5)
- Regulation authority
- CCR
What the official deficiency says
(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: Deficient Practice Statement Based on LPA observation, the licensee did not comply with the section cited above by staff maintaining resident #2 (R2) medication supplement in a plastic gum container and not in its original container; which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 03/19/2026 Plan of Correction The Licensee/Administrator shall retrain staff and provide inservice on medication management and provide documentation of training to the Licensing Division by POC due date.
Health conditions and treatmentsType B
- 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 LPA record review, the licensee did not comply with the section cited by not maintaining in the facility, a hospice care plan for resident #2(R2); which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 03/19/2026 Plan of Correction The Licensee/Administrator shall submit a self-certification to the Licensing Division that they have obtain a copy of R2's hospice plan of care by POC due date.