Facility condition and maintenanceType A
- Official classification
- Type A
- 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 in that the side gate was in need of repair/replacement to allow access from the inside and outside at all times. This lack of access from the exterior side gate posed an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 04/29/2026 Plan of Correction The facility designated Administrator stated that the side gate will be repaired/replaced to allow access from the exterior side of the gate to allow access for any responding emergency services at all times. A statement of correction, along with proof of updated side gate to allow exterior access, will be completed and submitted into CCL for review by this LPA by the due date.
Medication handling and storageType A
- Official classification
- Type A
- Official code
- 87465(c)(3)
- 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: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in that [1] out of [5] resident medications were not properly dispensed and documented as outlined by their assigned licensed medical professional which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 04/22/2026 Plan of Correction The facility designated Administrator stated that all facility staff will be trained, for no less than (1) hour in duration, on the principles of proper dispensing, documentation, and handling of all resident medications. A statement of correction, along with documented proof of training, will be completed and submitted into CCL for review by this LPA by the due date.