LOVELY COMMUNITY HEALTHCARE

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 as the fire door installed in bedridden room (#4) was held opened by a rubber door stopper which poses an immediate safety risk to persons in care.

Official plan of correction

POC Due Date: 07/10/2026 Plan of Correction During today's visit the Administrator removed the stopper and stated that the door will remain closed at all times. POC cleared.

Official classification

Type A

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

(8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as there were two containers with meat items without a label or information about the product inside of it which poses an immediate health risk to persons in care.

Official plan of correction

POC Due Date: 07/10/2026 Plan of Correction Product was removed from the refrigerator and disposed.

Official classification

Type A

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 and record review, the licensee did not comply with the section cited above as an inaccurate count of medication was observed for two residents which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 07/13/2026 Plan of Correction Administrator will hire a third party company, approved by the Department, to conduct medication audit and training. Administrator will provide date of training by POC due date and proof of training once training has been conducted.

Official classification

Type B

Official code

87470(a)(2)(D)

Regulation authority

CCR

What the official deficiency says

(2) Environmental cleaning and disinfection activities shall be performed following the manufacturers'instructions for proper use of the cleaning and disinfecting products. These activities shall be completed, at a minimum, as follows: (D) Facility items that cannot be disinfected shall be discarded immediately in an appropriate waste receptacle with a tight-fitting cover or otherwise made inaccessible to human contact or transmission. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as trash cans were full and and container did not have a tight-fitted lid which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 07/24/2026 Plan of Correction Administrator will replace all open trash cans with tight-fitted lids trash cans. Administrator will submit pictures of replaced trash cans.

Official classification

Type B

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, the licensee did not comply with the section cited above as " storage room " was unlocked and several chemicals and other items were inside and unattended which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 07/10/2026 Plan of Correction Assistant Administrator locked storage room immediately. POC cleared.

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, the licensee did not comply with the section cited above as cleaning solutions were unlocked and accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/09/2025 Plan of Correction At the time of the visit the Administrator locked the cabinet and spoke to about the importance of ensuring chemicals are locked and inaccessible to residents in care. Administrator will review regulation 87309 (a) with staff.

Official classification

Type B

Official code

87470(c)

Regulation authority

CCR

What the official deficiency says

(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. 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 in the infection control plan was not available which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/09/2025 Plan of Correction At the end of the visit the infection control plan was submitted. POC CLEARED.

Official classification

Type B

Official code

87309(a)(2)

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. (2) Any items in subsection (a)(1) that are transferred from their original container to another container shall have a legible label that indicates: 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 three (3) meat items did not have proper labels which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/09/2025 Plan of Correction At the time of the visit dates and labels were added to the three (3) meat items. POC CLEARED

Official classification

Type A

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and records review, the licensee did not comply with the section cited above. Licensee/Administrator is using full rail for R1 and R2 (non-hospice residents). This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/22/2024 Plan of Correction Licensee/administrator switched R2 rail to half and removed the full rail from R1's bed during the visit today. Licensee also reported that she will provide the necessary steps and assistance to ensure residents safety while under her care. Corrected during todays visit.

Official classification

Type B

Official code

87303

Regulation authority

CCR

What the official deficiency says

Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all facilities shall obtain a building permit. (b) The licensing agency may require the facility to acquire a local building inspection where the agency determines that a suspected hazard to health and safety exists. 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. Licensee/Administrator converted the garage area and laundry/closet space in the hallway into a staff room. Licensee/Administrator confirmed live-in staff spend the night in the converted areas. These conversions were not approved or permitted for living/sleeping space. This poses a potential health,safety and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/24/2024 Plan of Correction Licensee agreed to empty the areas and not allow staff to sleep in these areas immediately. Licensee shall submit an LIC500 to show 24hour awake staff on duty. Also Licensee may submit an LIC200 and updated facility sketch to obtain clearance for converted areas as staff room.

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, the licensee did not comply with the section cited above as medication was observed to be accessible in an unlocked drawer in the kitchen above the locked medication cabinet which poses an immediate health and safety of persons in care.

Official plan of correction

POC Due Date: 07/28/2023 Plan of Correction The licensee agreed to the following: 1. Lock all accessible medicaitons. Plan of correction met at the time of the visit.

Official classification

Type A

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, the licensee did not comply with the section cited above as medication for R1 was discovered to be in an unlabled container which was identified to be refused medication and to be sent for destruction however medication was not labeled which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 07/28/2023 Plan of Correction The licensee agreed to the following: 1. Ensure medications are in the approriatley labeled containers. Plan of correction met at the time of the visit.

Official classification

Type B

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as multiple boxes of cereal were found expired along with mayonaise and dressings which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 07/28/2023 Plan of Correction The licensee agreed to the following: 1. Dispose of expired food items. Plan of correction met at the time of the visit.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA’s observation, the licensee did not comply with the section cited above as the resident bathroom faucets deliver hot water measured between 124- and 125.8-degrees Fahrenheit, which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 08/05/2022 Plan of Correction The Administrator adjusted the thermostat during time of visit and has agreed to submit a hot water temperature log for five (5) days to show that the hot water is being maintained between temperatures 105- and 120-degrees Fahrenheit to CCL by 8/05/2022.

Official classification

Type B

Official code

87507(c)

Regulation authority

CCR

What the official deficiency says

87507(c) Admissions Agreement. Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident… and the licensee no later than seven days following admission… This requirement is not met as evidenced by: Based on interviews and record review, the licensee failed to comply with the section cited above as R1 does not have a signed admission agreement on file which poses a potential personal rights risk to residents in care.

Official plan of correction

The Administrator will submit a copy of R1’s signed admission agreement as proof to CCL by 5/02/2022.

Deadline recorded: May 2, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (f)(2) The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Based on LPA’s observations, the licensee did not comply with the section cited above as toxic items were observed in an accessible location to residents which posed an immediate health risk to persons in care.

Official plan of correction

Staff placed toxic items in an inaccessible location during the facility visit. Staff stated that they will provide documentation of scheduled staff training regarding regulation 87705(f)(2) to CCL by 8/27/21.

Deadline recorded: Aug 26, 2021. A deadline is not proof that correction was completed.