BELMONT VILLAGE ALBANY

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

87309 Storage Space and Access (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, interview and record review, the licensee did not comply with the section cited above by not properly storing required locked items for R1 and R2 which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 07/01/2025 Plan of Correction ED agreed to conduct in-service staff training, review R1's and R2's LIC 602, and submit proof of staff signatures to CCLD that staff reviewed the regulation.

Official classification

Type B

Official code

87632(d)(2)

Regulation authority

CCR

What the official deficiency says

87632 Hospice Care Waiver (d) If the Department grants a hospice care waiver it shall stipulate terms and conditions of the waiver as necessary to ensure the well-being of terminally ill residents and of all other facility residents...(2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services...or within five working days of admitting a resident already receiving hospice care services. The notice ...include...name...date of admission... name and address of the hospice.-This requirement was not met as evidenced by: Based on interviews and records reviewed the Licensee did not comply with the section cited above by not providing R1's Initiation of Hospice notification and LIC602 to CCLD which posed a potential health and safety risk to residents in care.

Official plan of correction

ED agreed to provide in-service training to all staff that are involved in decision making & procedures on the cited regulation. Submit a list of attendees signatures as proof to CCLD by POC date.

Deadline recorded: Dec 19, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87633(g)

Regulation authority

CCR

What the official deficiency says

87633 Hospice Care of Terminally Ill Residents (g) In addition to...Section 87211, Reporting Requirements... report...hospice services are interrupted or discontinued for any reason...any deviation from the resident’s hospice care plan, or other incident...- This requirement was not met as evidenced by:

Official plan of correction

ED agreed to provide in-service training to all staff that are involved in decision making & procedures on the cited regulation. Submit a list of attendees signatures as proof to CCLD by POC date.

Deadline recorded: Dec 19, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87507(f)

Regulation authority

CCR

What the official deficiency says

87507 Admission Agreements (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 interviews and records reviewed the Licensee did not comply with the section cited above by not abiding by R1's admission agreement which posed a potential health and safety risk to residents in care.

Official plan of correction

ED agreed to provide in-service training to all staff that are involved in decision making & procedures on the cited regulation. Submit a list of attendees signatures as proof to CCLD by POC date.

Deadline recorded: Dec 19, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (c) Licensees... with dementia shall be responsible ...(5) Each resident with dementia shall have an annual medical assessment ... annually, ... a reassessment of the resident’s dementia care needs.-This requirement was not met as evidenced by: Based on interviews and records reviewed the Licensee did not comply with the section cited above by not abiding by R1's admission agreement which posed a potential health and safety risk to residents in care.

Official plan of correction

ED agreed to provide in-service training to all staff that are involved in decision making & procedures on the cited regulation. Submit a list of attendees signatures as proof to CCLD by POC date.

Deadline recorded: Dec 19, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87224(i)

Regulation authority

CCR

What the official deficiency says

87224 Eviction Procedures (i)…a ... resident receiving hospice services ... resident's condition has changed ... joint determination has been made by the Department, the resident or resident's health care surrogate decision maker, the resident's hospice agency, a physician... - This requirement was not met as evidenced by: Based on interviews and records reviewed, Licensee failed to ensure the facility sought joint determination before denying R1’s return to the facility after being released for treatment of emergency services which posed an immediate health and safety risk to residents in care.

Official plan of correction

ED agreed to provide in-service training to all staff that are involved in decision making procedures on the cited regulation. Submit a list of attendees signatures as proof to CCLD by POC date.

Deadline recorded: Dec 14, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(2)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports…(2) Occurrences…epidemic outbreaks…major accidents which threaten the welfare, safety or health of residents, personnel or visitors…within 24 hours either by telephone or facsimile… - This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by notifying CCLD of the incident within 24 hours which poses a potential health and safety risk to the persons in care.

Official plan of correction

ED agreed to conduct in-service staff retraining on reporting per the regulation and submit proof of completed certifications to CCLD by POC.

Deadline recorded: Oct 15, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(c)(4)

Regulation authority

CCR

What the official deficiency says

87705 (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s... safety and health care needs as identified in his/her current appraisal. This requirement was not met as evidence by: Based on LPAs interviews and record review the Licensee did not comply with the section cited above in supporting R1's needs, which poses a potential health and safety risk to residents in care.

Official plan of correction

Execuive Director implemented a plan to have a private companion for R1 starting 2/29/2024. Deficiency cleared.

Deadline recorded: Mar 5, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(d)(2)

Regulation authority

CCR

What the official deficiency says

87405(d)(2) ADMINISTRATOR - QUALIFICATIONS AND DUTIES (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)...(2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by: Based on observation on 7/22/22, Licensee did not comply with the regulation cited above by not physically distancing residents in accordance to PIN 21-49-ASC and local public health guidance. AGPA and LPA observed 5 residents on wheel chairs in one round dining table in memory care which poses a potential health and safety risk to persons in care.

Official plan of correction

By POC date, Administrator agrees to review facility's infection control plan with all staff and submit a self-certification letter to CCLD.

Deadline recorded: Dec 7, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements. A written report shall be submitted to the licensing agency...within seven days of the occurrence of any of the events specified... This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by not submitting incident report to CCLD which poses a potential health and safety risk to the persons in care.

Official plan of correction

Facility has agreed to conduct an in-service with necessary staff on reporting requirements and submit staff sign-in sheet & training materials to CCLD by POC date.

Deadline recorded: Apr 14, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: 2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above resulting R1 sustaining skin tear due to improper handling during transfer which poses an immediate health and safety risk to the residents in care.

Official plan of correction

Facility has agreed to re-train all staff on proper transfer techniques when transferring residents. Facility will submit training materials and staff sign in sheet to CCLD by 02/03/2023. $500.00 immediate civil penalty is assessed.

Deadline recorded: Jan 20, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87466

Regulation authority

CCR

What the official deficiency says

The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional..... This requirement is not met as evidenced by: Based on interview and records review, the licensee did not comply with the section cited above by not properly observing resident's changes in condition.

Official plan of correction

Facility will train all staff on documenting residents' observation and will submit staff sign-in sheet to CCLD by POC date.

Deadline recorded: Feb 3, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(g)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including... This requirement is not met as evidenced by: Based on record review and interviews, Licensee did not comply with the regulation above, facility failed to take R1 medical facility or to call 9-1-1 in timely manner after sustaining skin tear, which poses an immediate health and safety risk to residents in care.

Official plan of correction

Facility will train all staff on the regulation cited above, a cpy of training with staff names and signatures will need to be submitted to CCL by POC date.

Deadline recorded: Feb 3, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

CARE OF PERSONS WITH DEMENTIA (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5)Each resident with dementia shall have an annual medical assessment as specified...least annually.. This requirement was not met as evidenced by: Based on record review, Licensee did not comply with regulation cited above. On 01/19/2023 LPA observed R3's medical assessment was last completed on 04/2021 which poses a potential health and safety risk to persons in care.

Official plan of correction

Assistant Executive Administrator agreed to submit a up to date physician's report for R3, to CCL by POC date.

Deadline recorded: Feb 3, 2023. A deadline is not proof that correction was completed.