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), or (record review)], the licensee did not comply with the section cited above by not having the drawer obtaining sharps locked which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 01/30/2026 Plan of Correction Administrator has agreed to provide a training to staff and provide proof with signatures and understanding of the regulation cited to LPA by POC due date.
Medication handling and storageType B
- Official classification
- Type B
- Official code
- 87465(c)(2)
- 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: (2) Once ordered by the physician the medication is given according to the physician's directions. 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 administering medication per physicians orders and/or not providing signatures when medication to administered to residents which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 02/06/2026 Plan of Correction Administrator has agreed to provide in service training to staff and provide proof to LPA with signatures by POC due date.
Admission, assessment, and evictionType B
- 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 [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 02/13/2026 Plan of Correction Administrator has agreed to obtain a new physician report (LIC602A) for R3, signed 602 for R4, and TB results for R1 and provide proof to LPA by POC due date.
Fire safety and emergency preparednessType B
- Official classification
- Type B
- Official code
- 1569.695(a)
- Regulation authority
- HSC
What the official deficiency says
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: 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 a disaster plan on file which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 02/06/2026 Plan of Correction Administrator has agreed to create disaster plan and provide proof 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 [(observation) (interview) (record review)], the licensee did not comply with the section cited above by not conducting a diaster drill since December 2024 which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 02/06/2026 Plan of Correction Administrator has agreed to conduct a disaster drill and continue to do so quarterly Administrator will provide proof of disaster drill to LPA by POC due date.