Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
12/31/2025
Section Cited
CCR
87303(a) | 1
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7 | Maintenance and Operation
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 facility was found to be deficient as | 1
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7 | The facility designated Administrator stated that all four doors will be reviewed and any found to not be functioning will be repaired/replaced as necessary to ensure proper access to/from the interior and exterior for all residents at all times. |
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14 | evidenced by the observation of (3) out of (4) doors leading out of this facility were not functioning properly when their press pads were activated. The doors did not automatically open when the press pads were activated posing a potential threat to the Health, Safety, and Personal Rights of all residents in care. | 8
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14 | A statement of correction, along with receipts of all updated work performed for the doors, will be completed and submitted into CCL by the due date. |
Type B
12/31/2025
Section Cited
CCR
87555(b)(33) | 1
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7 | General Food Service Requirements
Tableware and tables, dishes, and utensils shall be sufficient in quantity to serve the residents.
This facility was found to be deficient as evidenced by the use of paper products for dishes and utensils in the memory care unit | 1
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7 | The facility designated Administrator stated that the dishes, utensils, and kitchen supplies for the memory care unit will be reviewed to make sure that they are plentiful and able to meet the needs of the facility residents at all times.
A statement of correction, along with copies |
| 8
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14 | which posed a potential threat to the Health, Safety, and Personal Rights of all residents in care. | 8
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14 | of all updated supplies ordered for the memory care unit, will be completed and submitted into CCL by the due date. |
NARRATIVE |
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32 | necessary silverware.
Based on interviews conducted during this investigation, it was learned that there were two primary phones being used in the memory care unit at this time. It was learned that one land line was located in the medication room and the other was in the office for the Activities Director.
It was learned that there was not a direct line to the memory care unit and all calls were forwarded over from the front desk in the Assisted Living side.
It was learned that memory care staff did not have direct access to the phone lines in the medication room and office of the Activities Director. It was learned that memory care staff only carried a mobile device used to communicate and receive notifications from the front desk. They were not tasked to answer or return calls from this land line in the medication room.
It was learned that the medication technician only had access to the phone placed in the medication room but had other tasks and duties related to handling, dispensing, and documentation of the resident medications that took priority while on duty.
It was learned that, if time permitted, the medication technician would be able to return any missed calls and voice mails at a later time during their shift.
It was learned that the only other land line for the Activities Director was only accessible to this particular individual in their office. Memory care caregivers and medication technicians did not have access to receive, retrieve, or return any phone calls at this time from this particular office land line.
Based on a review conducted for a physical plant review, it was observed that there were (4) individual doors located throughout this facility which had a press pad which could be used to activate and open the doors automatically leading out into the courtyard at this time.
It was observed that the only door that was functioning when the press pad was activated was the door directly outside of the Assisted Living dining room. The interior pad and exterior pad, when activated, did automatically open the door at this time.
It was observed that north facing door with its press pad, when activated, did automatically open the door but only functioned properly when activated from the interior. It was observed that the exterior pad was not functioning at this time when activated to automatically open up the door.
It was observed that the fireside room exit door, with its interior press pad, was not functioning at this time.
It was observed that the exterior press pad for the exterior door leading into the bistro area was also not functioning at this time as well. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
12/31/2025
Section Cited
HSC
1569.313 | 1
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7 | The facility’s policy concerning family visits and communication shall be designed to encourage regular family involvement with the resident client and shall provide ample opportunities for family participation in activities at the facility. | 1
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7 | The facility designated Administrator stated that the communication policy for the memory care unit will be addressed to better deal with communication coming into this unit. A statement of correction, along with updated communication plans for the memory care unit, will be completed and submitted into |
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14 | This facility was found to be deficient as evidenced by multiple phone calls and voicemails not being returned in a timely manner which posed a potential threat to the Health, Safety, and Personal Rights of all residents in care. | 8
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14 | CCL by the due date. |
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