Licensing and administrationType B
- Official classification
- Type B
- Official code
- 1569.618(c)(3)
- Regulation authority
- HSC
What the official deficiency says
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. Deficient Practice Statement Based on record review, the licensee did not ensure staff have CPR training for 8 out of 12 [S1-S8] staff which poses a potential health and risk to persons in care.
Official plan of correction
POC Due Date: 08/14/2026 Plan of Correction Administrator stated staff will attend CPR training, once completed, administrator will submit proof of training by POC due.
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87411(c)(1)
- Regulation authority
- CCR
What the official deficiency says
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. Deficient Practice Statement Based on record review, the licensee did not ensure staff have CPR training for 8 out of 12 [S1-S8] staff which poses a potential health and risk to persons in care.
Official plan of correction
POC Due Date: 08/14/2026 Plan of Correction Administrator stated staff will attend CPR training, once completed, administrator will submit proof of training by POC due.
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. Deficient Practice Statement Based on review of records, the licensee did not ensure quarterly drills were conducted, nor documented, which posed a pontential health, safety and personal rights risk to 5 of 5 residents in care.
Official plan of correction
POC Due Date: 08/14/2026 Plan of Correction Licensee staff House manager agreed to review emegency drill policy, conduct an emegency drill with all staff and submit proof to the LPA by POC date.
Resident rightsType B
- Official classification
- Type B
- Official code
- 1569.269(a)(2)
- Regulation authority
- HSC
What the official deficiency says
Enumerated rights; severability. To be granted a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interviews, the licensee did not comply with the section cited above in 1 of 5 persons in care (Resident #1). R1's privacy was violated due to R1 being heard by staff 24 hours per day via baby monitor, which poses a potential Personal Rights risk to residents in care.
Official plan of correction
POC Due Date: 07/14/2026 Plan of Correction Licensee staff stated she was not aware of the laws concerning audio surveillance. Staff removed the baby monitor immediately. Licensee staff stated they will submit a statement of discontinuation of the use of the baby monitors by 8/14/2026