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, interview, and record review, the licensee did not comply with the section cited above by not having the kitchen knives locked which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 01/27/2026 Plan of Correction House Manager immediately locked knives, Administrator will conduct training to all staff understanding the regulation and provide proof with signatures to LPA by POC due date.
Staffing, personnel, and trainingType B
- Official classification
- Type B
- 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. Each personnel record shall contain the following information: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and record review, the licensee did not comply with the section cited above by Administrator having an incomplete file which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 02/01/2026 Plan of Correction Administrator will submit health screening with TB results, CPR certificate, and trainings to LPA 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 observation, interview, record review, the licensee did not comply with the section cited above by punching medication's and transferring them into a clear container which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 02/01/2026 Plan of Correction Administrator will conduct a training with staff and statement of understanding medication can not be transferred from it's originally container.
Medication handling and storageType B
- Official classification
- Type B
- Official code
- 87465(c)(1)
- Regulation authority
- CCR
What the official deficiency says
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can 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: (1) There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication, all of the information specified in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication of when the physician should be contacted for a medication reevaluation. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation,interview, and record review, the licensee did not comply with the section cited above not providing R1's mediation refusal notes to physician which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 02/01/2026 Plan of Correction Administrator will provide documentation to LPA of R1's physician contact about medication refusal 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 observation, interview, and record review, the licensee did not comply with the section cited above by not conducting quarterly disaster drills which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 02/02/2026 Plan of Correction Administrator will conduct disaster drills with residents and staff and provide proof to LPA by POC due date and continue to conduct drills quarterly.
Fire safety and emergency preparednessType B
- Official classification
- Type B
- Official code
- 1569.695(f)(2)(D)
- Regulation authority
- HSC
What the official deficiency says
(f) A facility shall have both of the following in place: (2) A set of keys available to facility staff on each shift for use during an evacuation that provides access to all of the following: (D) All facility cabinets and cupboards or files that contain elements of the emergency and disaster plan, including, but not limited to, food supplies and protective shelter supplies. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, record review, the licensee did not comply with the section cited above by not having emergency food supply which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 02/02/2026 Plan of Correction Administrator will purchase a supply of emergency food for 72 hours in an event of an emergency, and provide proof of purchase (photo and receipt) to LPA by POC due date.
Dementia careType B
- Official classification
- Type B
- Official code
- 87705(f)(2)
- Regulation authority
- CCR
What the official deficiency says
(f) Licensees that lock exterior doors or perimeter fence gates shall meet the following initial and continuing requirements: (2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or perimeter fence gates and that facility staff on all shifts have access to, and know how to use, equipment needed to unlock exterior doors or perimeter fence gates. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation,interview,record review, the licensee did not comply with the section cited above by locking both side gates which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 02/01/2026 Plan of Correction House manager unlocked both side gates, Administrator will review regulation and provide understanding that side gates must remained unlocked at all times to LPA by POC due that