APPLETON HOMES

Official classification

Type B

Official code

87468.1(a)(11)

Regulation authority

CCR

What the official deficiency says

To have their visitors...permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This requirement is not met as evidenced by Based on interviews and record review, the licensee did not comply with the section cited above as staff prevented R1 from having a visitors which poses as a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee agreed to review section cited then submit a statement of understanding and a written plan to ensure future compliance and submit to CCLD via email by COB 02/27/2026

Deadline recorded: Feb 27, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87205(b)

Regulation authority

CCR

What the official deficiency says

If the licensee is a corporation or an association, the governing body shall be active, and functioning in order to assure accountability.This requirement is not met as evidenced by Based on interviews and record review, the licensee did not comply with the section cited above the as the licensee's corporationwas in a suspended status which poses as a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee stated they corporation status will be in good standing by next month. Licensee also agreed to review section cited and provide a statement of understanding and a writted plan to ensure future complaince then send to CCLD via email by COB 02/27/2026

Deadline recorded: Feb 27, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87507(f)

Regulation authority

CCR

What the official deficiency says

(f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above as the licensee did not obtain required documents and did not conduct a pre-placement appraisal which poses/posed an immediate health, safety, and personal rights risk to residents in care.

Official plan of correction

The Licensee will review their admission agreement and send CCLD a statement of understanding by POC due date.

Deadline recorded: Aug 9, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87208(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so … This requirement was not met as evidence by: Based on interview and record review, the licensee did not comply with the section cited above as the licensee did not issue the resident’s representative a refund which poses/posed an immediate health, safety, and personal rights risk to residents in care.

Official plan of correction

The Licensee will issue R1's representative a refund and send CCLD proof by POC due date.

Deadline recorded: Aug 9, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87615(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (2) Gastrostomy tubes. This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section as the licensee retained a resident with a prohibted health condition who was not on hospice during the time of admission which poses/posed an immediate health, safety, and personal rights risk to residents in care.

Official plan of correction

The Licensee will review regulations and provide CCLD a statement of understanding by POC due date.

Deadline recorded: Aug 9, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: 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 1 resident's bed placement did not allow access to the exit and did not provide ample space for a passageway which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/08/2025 Plan of Correction The Licensee and staff pushed the resident's bed away from the exit and created a passageway to fit a walker and wheelchar. POC Cleared.

Official classification

Type A

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above in the emergency side exit passageway was obstructed which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/09/2025 Plan of Correction The Licensee will discard of the items obstructing the passageway and send CCLD proof of unobstructed passage by POC due date.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above in medications were accessible in a file cabinet which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/09/2025 Plan of Correction The Licensee will discard or properly secure the medications in the file cabinet and send CCLD proof by POC due date.

Official classification

Type A

Official code

87307(a)(2)(C)

Regulation authority

CCR

What the official deficiency says

(a) ... The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (C) No bedroom of a resident shall be used as a passageway to another room, bath or toilet. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview, the licensee did not comply with the section cited above in residents who do not reside in Bedroom #5 utilized the private restroom in Bedroom #5 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/09/2025 Plan of Correction The Licensee will review regulations, advise staff, and submit a statement of understanding to CCLD by the POC due date.

Official classification

Type B

Official code

1569.618(c)(4)

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: (4) Ensure that the facility is clean, safe, sanitary, and in good repair at all times. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above in the staff room was not secured which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/15/2025 Plan of Correction The Licensee will install a lock on the staff room and advise staff to ensure the staff room is locked at all time and send CCLD proof by POC due date.

Official classification

Type B

Official code

87555(b)(28)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above in non-perishable food cans were expired which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/15/2025 Plan of Correction The Licensee will review the facility's food supply and discard of expired food and send CCLD proof by POC due date.

Official classification

Type B

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. 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 5 residents medications were not properly documented which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/15/2025 Plan of Correction The Licensee will update 5 resident medications on the CSMDR, review regulations, and submit a statement of understanding. The Licensee will provide the updated CSMDR and statement of understanding by POC due date.

Official classification

Type B

Official code

87465(e)

Regulation authority

CCR

What the official deficiency says

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. 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 residents did not have a PRN Authorization letter which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/15/2025 Plan of Correction The Licensee will obtain PRN Authorization Letters and update current letters to reflect the current PRN medications the residents are prescribed and send CCLD the PRN letters by POC due date.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. 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 3 residents did not have completed documents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/22/2025 Plan of Correction The Licensee will complete the residents' documents with the residents' representative and send CCLD the completed documents with signatures by POC due date.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

87309 Storage Space and Access (a)... the licensee shall ensure that ... knives...tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended... This requirement is not met as evidenced by: Based on observation and interview the licensee did not comply with the section cited above as multiple tools were left unattended on the facility's back patio which poses an immediate safety risk to clients in care.

Official plan of correction

Licensee secured the tools at the time of the visit. POC cleared.

Deadline recorded: Mar 13, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.312(a)

Regulation authority

HSC

What the official deficiency says

§1569.312 Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision... This requirement is not met as evidenced by: Based on interview and file review the licensee did not comply with the section cited above as R1 suffered a fall at the facility and no safety measures were in place to minimize the risk of falls during the timeframe R1 fell which poses a potential health and safety risk to clients in care.

Official plan of correction

Licensee will submit their plan on how they will minimize the danger for future fall risk clients, and a statement of understanding confirming that they understand the importance of providing appropriate accomidations and supervision to at risk clients. Licensee will submit POC no later than due date.

Deadline recorded: Mar 27, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(d)(3)

Regulation authority

CCR

What the official deficiency says

(3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents. This requirment wa not met as evidence by: Based on interviews and records review the licensee did not comply with regulation cited as R3 was suspended in their hoyer lift for an extended period of time due to staff failing to demonstrate knowledge for use of hoyer lift, which posed a potential health and safety risk to residents in care.

Official plan of correction

Administrator agreed to review section cited and provide in-service training with staff regarding proper use of hoyer lift then submit proof of training and statement of understanding to LPA via email by COB 02/14/2025.

Deadline recorded: Feb 14, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.69(e)(3)(C)

Regulation authority

HSC

What the official deficiency says

(e) Each person who provides employee training under this section shall meet the following education and experience requirements: (3) The licensed residential care facility for the elderly shall maintain the following documentation on each person who provides employee training under this section: (C) The times, dates, and hours of training provided. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review and interview, the licensee did not comply with the section cited above as staff training does not have times, dates, and hours of training provided as Administrator stated they only sign off on all the training on one (1) day, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/11/2024 Plan of Correction The Licensee will review Regulation and submit a statement of understanding to CCL on or before POC due date.

Official classification

Type B

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review and inetrview, the licensee did not comply with the section cited above as not all medication being received by the facility is being proprely documented on the CSMDR, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/11/2024 Plan of Correction The Licensee will create a plan on how the faciltiy will ensure all medication is properly documented on the CSMDR and submit to CCL on or before POC due date.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (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: Both bathrooms and kitchen observed in disrepair. Bathroom wall observed damaged from either water or other; needs repair and fresh paint; Kitchen ceiling lighting observed in disrepair/out of order. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/25/2023 Plan of Correction Licensee/Administrator stated she will discuss repairs with property owner and provide a plan and completion date of needed repairs by 9/25/2023.