POINT AT ROCKRIDGE, THE

Official classification

Type A

Official code

87465(g)

Regulation authority

CCR

What the official deficiency says

The licensee shall immediately telephone 9-1-1 …an imminent threat to a resident’s health…apparent life-threatening medical crisis... This requirement was not met as evidence by: Based on interviews and file review, the licensee did not comply with the section cited above by staff not immediately calling 911 when a resident was in need of emergency care which poses a potential health and safety risk to persons in care.

Official plan of correction

By POC date, Licensee will do an in service training to all staff on the regulation regarding calling 911, and submit a to the facility and submit proof of training to LPA.

Deadline recorded: Jun 12, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

Personnel Requirements - General. (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...This requirement is not met as evidence by: Based on record review and interviews, licensee did not comply with the section cited above by having resident leave the facility unassisted which poses a potential health and safety risk to the persons in care.

Official plan of correction

The facility has already address this issue and made changes to help prevent further elopements. Memory Care director has taken the key fobs away from non memory care staff and given an in-service training to all staff

Deadline recorded: May 29, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(d)

Regulation authority

CCR

What the official deficiency says

(d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement... This requirement was not met as evidence by: Based on interview and record review the Licensee did not comply with the section cited above in having S2 fingerprinted and associated to the facility which poses a potential health and safety risk to persons in care.

Official plan of correction

Generations Program Director agreed to have S2 fingerprinted and submit document to CCLD by POC date.

Deadline recorded: Nov 1, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall have a qualified and currently certified administrator. ...and shall be on the premises a sufficient number of hours... When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications... to be responsible and accountable for management and administration of the facility... This requirement was not met as evidence by: Based on interview and observation the Licensee did not comply with the section cited above in having a qualified and certified administrator, which poses a potential health and safety risk to persons in care.

Official plan of correction

Generations Program Director agreed to hire a new administrator, and submit documents to CCLD by POC date.

Deadline recorded: Nov 11, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(3)

Regulation authority

CCR

What the official deficiency says

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature... This evidence was not met by: Based on record review and interviews the Licensee did not comply with the section cited above in keeping resident free from humiliation, which poses a potential health and safety risk to person in care.

Official plan of correction

Generations Program Director agreed to implement a plan on the hiring process from other agencies going forward to CCLD by POC date.

Deadline recorded: Nov 1, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidence by: Based on interviews the Licensee did not comply with the section cited above in staff having dignity with residents, which poses a potential health and safety risk to persons in care.

Official plan of correction

Generations Program Director agreed to conduct an in-service training for all staff on personal rights and submit documentation to CCLD that the training has been completed by POC date.

Deadline recorded: Nov 1, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary... In facilities licensed for sixteen or more, sufficient support staff shall be employed... Additional staff shall be employed as necessary... The licensing agency may require any facility to provide additional staff... This requirement was not met as evidence by: Based on interviews the Licensee did not comply with the section above in attending to resident needs which poses a potential health and safety risk for persons in care.

Official plan of correction

Generations Program Director agreed to review the plan and retrain staff on YouSafely, and submit documentation to CCLD by POC date.

Deadline recorded: Nov 1, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(3)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities. To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature... This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by staff performing ADL care in a rough manner which poses a potential health and safety risk to the persons in care.

Official plan of correction

Executive Director has agreed to conduct training for staff and submit staff sign in sheet & materials to CCLD by POC date.

Deadline recorded: Sep 23, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

Additional Personal Rights of Residents in Privately Operated Facilities. To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers...and competency to meet their needs. This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by charging R2 services that was not provided which poses a potential personal rights violation to the persons in care.

Official plan of correction

Executive Director (ED) has refunded the overcharge fees to R2 and family. ED and staff did an audit for all residents in AL and MC for their level of services and monthly charges. Additionally, ED has created a billing procedure to prevent future billing errors and provided a copy to LPA during visit. Deficiency cleared.

Deadline recorded: Nov 30, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate…. This requirement is not met as evidenced by… Based on records review and interview, the licensee did not comply with the section cited above. LPA observed staff didn’t reappraise resident when resident was admitted to hospital two times in 24 hours which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator agrees to review and understand regulation, retrain staff, and submit in-service training with staff signatures to CCL by the POC due date.

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

Official classification

Type B

Official code

87463(c)

Regulation authority

CCR

What the official deficiency says

87463 Reappraisals (c) The licensee shall arrange a meeting with the resident, the resident’s representative…once every 12 months… This requirement is not met as evidenced by… Based on records review and interview, the licensee did not comply with the section cited above. LPA observed staff didn’t reappraise resident annually which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator agrees to review and understand regulation, retrain staff, and submit in-service training with staff signatures to CCL by the POC due date.

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

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (a) Each licensee shall...including, but not limited to...(1)A written report shall be submitted to the licensing agency... (D) Any incident...welfare, safety or health of any resident... This requirement is not met as evidenced by… Based on observation, interview, and record review, the licensee did not comply with the section cited above. LPA observed resident's falls resulted to be admitted to hospital twice on 11/7/22 and 11/8/22 were not reported to CCLD which poses a potential health and safety concern to persons in care.

Official plan of correction

Administrator agrees to review the regulation, and submit a self-certification of understanding regulation to CCL by the POC due date. A civil penalty of repeating violation $250 is assessed today.

Deadline recorded: Feb 13, 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

87705 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… This requirement is not met as evidenced by… Based on records review and interview, the licensee did not comply with the section cited above. LPA observed staff didn’t update physician’s report for residents with dementia annually which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator agrees to review and understand regulation, retrain staff, and submit in-service training with staff signatures to CCL by the POC due date.

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

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.... This requirement is not met as evidenced by… Based on records review and interview, the licensee did not comply with the section cited above. LPA observed that no janitor was on duty for almost 2 months which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator agrees to review regulation, and submit a self-certification of understanding regulation section code 87303 to CCL by the POC due date.

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

Official classification

Type B

Official code

1569.652(a)

Regulation authority

HSC

What the official deficiency says

1569.652 Termination of admission agreement upon death of resident... (a) No fees shall accrue once all personal property belonging to the deceased resident is removed from the living unit. This requirement is not met as evidenced by… Based on observation, record review, and interview, the licensee did not comply with the section cited above, LPA observed that resident who passed on 10/30/22 and monthly rent was accured for December 2022 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Regional Vice President agrees to review regulations and retrain staff, submit proof of in-service training with staff signatures to CCL by POC due date.

Deadline recorded: Jan 17, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.652(c)

Regulation authority

HSC

What the official deficiency says

1569.652 Termination of admission agreement upon death of resident... (c) A refund of any fees...within 15 days after the personal property is removed. This requirement is not met as evidenced by… Based on observation, record review, and interview, the licensee did not comply with the section cited above, LPA observed that resident who passed on 10/30/22 and room vacant on 11/19/22 but was not received refund for partial of rent timely which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Regional Vice President agrees to review regulations and retrain staff, submit proof of in-service training with staff signatures to CCL by POC due date. RP received two refund checks $2302 & $9655 on today's date.

Deadline recorded: Jan 17, 2023. 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)The following shall be stored inaccessible to residents with dementia: (2)...toxic substances such as....cleaning supplies and disinfectants. This requirement is not met as evidenced by… Based on observation, the licensee did not comply with the section cited above. LPA observed 2 bottles of disinfectant and cleaner in memory care resident's room 201 and 205 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator removed 2 bottles of chemicals and instructed staff to lock them up during visit. Administrator agrees to retrain staff and submit proof of training with staff signatures to CCLD by the POC due date.

Deadline recorded: Nov 30, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (a) Each licensee shall...including, but not limited to...(1)A written report shall be submitted to the licensing agency... (D) Any incident...welfare, safety or health of any resident... This requirement is not met as evidenced by… Based on observation, interview, and record review, the licensee did not comply with the section cited above. LPA observed resident's fall resulted to be admitted to hospital on 9/8/2022 was not reported to CCLD which poses a potential health and safety concern to persons in care.

Official plan of correction

Administrator agrees to review the regulation, and submit a self-certification of understanding regulation and a LIC624 for subject resident to CCL by the POC due date.

Deadline recorded: Sep 30, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(h)(8)

Regulation authority

CCR

What the official deficiency says

87405 Administrator - Qualifications and Duties. (h) The administrator shall have the responsibility to: (8) Have the personal characteristics, physical energy and competence to provide care and supervision and, where applicable, to work effectively with social agencies. This requirement is not met as evidenced by… Based on observation, interview, and record review, the licensee did not comply with the section cited above. LPA observed facility didn't respond to hospital for resident's returning which poses a potential health and safety concern to persons in care.

Official plan of correction

Administrator agrees to review the regulation and submit a self-certification of understanding regulation to CCL by the POC due date.

Deadline recorded: Sep 30, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.69

Regulation authority

HSC

What the official deficiency says

1569.69 Employees assisting residents with self-administration of medication; training requirements 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, S1 was observed passing medication to residents without required trainings which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/21/2022 Plan of Correction Administrator agreed to provide policy and procedure of staff training and submit to CCL by POC due date.