TAR SPRINGS HOME CARE

Official classification

Type B

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

87608(a)(5)(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: Based on observation and reviewed records, R1 is currently not on hospice care and using a hospital bed with full rails, which poses/posed a potential health and safety and personal rights risk to the resident in care.

Official plan of correction

R1 has doctor’s order for half rail bed. Staff removed full bed rails during visit and replaced with half bed rails. POC cleared during visit.

Deadline recorded: Jul 7, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

87465(h)(2) Centrally stored medicines shall be kept in a safe and locked place... not accessible to persons other than employees... This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above when LPA and L1 observed R1’s Lactulose medication bottle stored on the kitchen counter unlocked accessible to the residents in care, which poses an immediate health and safety risk to person in care.

Official plan of correction

POC Due Date: 05/29/2026 Plan of Correction Staff immediately locked R1’s medication. POC cleared during visit.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

87309 (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, LPA and L1 observed three shovels and a lopper trimmer tool in the garage by the water heater unlock, which poses an immediate health and safety risk to the residents in care.

Official plan of correction

POC Due Date: 05/29/2026 Plan of Correction Staff immediately locked the tools. POC cleared during visit.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

87465(h)(2) Centrally stored medicines shall be kept in a safe and locked place... not accessible to persons other than employees... This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interviews conducted, the licensee did not comply with the section cited above when LPA and L1 observed R2’s medication Multivitamin stored unlock on television stand in resident’s room and R4 medication Milk of Magnesia stored unlock on dresser in the resident’s room which poses an immediate health, safety or personal rights risk to person in care.

Official plan of correction

POC Due Date: 04/30/2025 Plan of Correction Staff immediately removed R2 and R4’s medication to locked kitchen drawer. POC cleared during visit.

Official classification

Type A

Official code

87465(d)(3)

Regulation authority

CCR

What the official deficiency says

87465(d)(3) The date and time …medication was taken, the dosage taken, and the resident’s response shall be documented and maintained in the resident’s facility record. This requirement was not met as evidenced by: Deficient Practice Statement Based on observations, records reviewed, and interviews conducted, S1 administered R1 medication Levothyroxine 75mcg and Donepezil Hcl 5mg in the morning ON 04/29/25 at 08:00am, and did not record in the resident’s MARs, which poses/ posed a potential health and safety risk for the person in care.

Official plan of correction

POC Due Date: 04/30/2025 Plan of Correction S1 will be retrained in in-service training on proper administering medication and documentation. Licensee will submit documentation of training topics and staff attendance to CCL by POC due date 04/30/25.

Official classification

Type B

Official code

87458(c)(1)(A)

Regulation authority

CCR

What the official deficiency says

87458(c)(1)(A) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A)Communicable tuberculosis. This requirement is not met as evidenced by: Deficient Practice Statement Based on records reviewed, R1 and R2 do not have TB result on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/19/2025 Plan of Correction Licensee will submit proof of TB result or X-ray results for R2 and R3 to Fresno CCL by POC due date 05/19/25.

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

87608 (a)(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview conducted, observation, and records reviewed, R1 uses half bed rail on hospital bed with no doctor’s order, which poses/posed a potential health and safety and personal rights risk to the resident in care.

Official plan of correction

POC Due Date: 05/05/2025 Plan of Correction Licensee shall obtain doctor orders for R1 indicating the need for half bed rail and if physician do not indicate the need for half bed rail, hail rail must be removed by POC due date 05/05/25.

Official classification

Type A

Official code

1569.311

Regulation authority

HSC

What the official deficiency says

Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. 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 Licensee not having a working carbon monoxide detector, which poses an immediate health, safety or personal rights risk to persons in care. Civil Penalty issued.

Official plan of correction

POC Due Date: 05/24/2024 Plan of Correction Licensee agrees to have an operating carbon monoxide detector in the facility at all times. Correction completed during visit.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in Licensee had two different start dates for R1's medication and R1 missed a medication, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/31/2024 Plan of Correction Licensee agrees to conduct a 2 hour medication training for staff and will submit agenda, what approved training resource was used, who conducted the training and staff trained by POC due date 6/3/24.

Official classification

Type A

Official code

87465(h)(4)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in R1's quantity of 30 label was crossed out and 52 was handwritten in, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/03/2024 Plan of Correction Licensee agrees to conduct a training on altering the label of a prescribed medication and will submit who was trained who conducted the training and where the approved training resource used and the staff trained by POC due date 4/3/24.

Official classification

Type A

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. 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 Administrator receiving multiple citations and is non compliant in Health and Safety and Title 22 in various areas, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/03/2024 Plan of Correction Llicensee submit a plan on how these regulations will be met and will become compliant by POC due date 6/3/24.

Official classification

Type A

Official code

87705(j)

Regulation authority

CCR

What the official deficiency says

(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. 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 Licensee did not have the front door and the garage door delay egrees turned on and the back door to the backyard did not have a delay egrees, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/03/2024 Plan of Correction Licensee agrees to keep delay egress on and put a delay egress on the back door by POC due date 6/3/24. Licensee agrees to submit a photo to LPA .

Official classification

Type A

Official code

87705(l)(3)

Regulation authority

CCR

What the official deficiency says

(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (3) The licensee shall obtain a waiver from Section 87468(a)(6), to prevent residents from leaving the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation interview, the licensee did not comply with the section cited above in Licensee had an extra lock on the front door to prevent residents from exiting the facility, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/24/2024 Plan of Correction Licensee agrees to remove lock. Licensee removed lock during visit. POC cleared.

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 Licensee did not log 2 of R1's medications on the centrally stored log, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/03/2024 Plan of Correction Licensee agrees to conduct a 1 hour training on logging medications and will submit who was trained who conducted the training and where the approved training resource used and the staff trained by POC due date 4/3/24.

Official classification

Type B

Official code

87606(f)(1)(A)

Regulation authority

CCR

What the official deficiency says

(f) To accept or retain a bedridden person, a facility shall ensure the following: (1) The facility's Plan of Operation includes a statement of how the facility intends to meet the overall health, safety and care needs of bedridden persons. (A) The facility's Emergency Disaster Plan, addresses fire safety precautions specific to evacuation of bedridden residents in the event of an emergency or disaster. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in Licensee did not include an evacuation plan of bedridden residents in disaster plan, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/03/2024 Plan of Correction Licensee agrees to add to the emergency plan on how to evacuate bedridden residents by POC due date 6/3/24

Official classification

Type B

Official code

87625(b)(3)

Regulation authority

CCR

What the official deficiency says

(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. 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 Licensee did not ensure residents incontinence was changed every 2 hours which caused an odor of urine, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/03/2024 Plan of Correction Licensee agrees to conduct training on incontinence care and submit resource of training, trainer, agenda, and staff trained by POC due date 6/3/24.

Official classification

Type B

Official code

87633(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in Licensee does not have a care plan that meets the requirements and does not have staff training regarding hospice care for R1, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/03/2024 Plan of Correction Licensee agrees to get a correct hospice care plan that meets the regulation and staff training for R1's hospice care plan regarding use of oygen and turning R1 by POC due date 6/3/24.

Official classification

Type A

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

87202 Fire Clearance (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 was not met as evidenced by: Licensee has 2 out of 5 residents bedridden and is only fire cleared for one resident in room 5. R1 is in room 1 and R2 is in room 2 which are not fire cleared rooms which poses and immediate health safety and or personal rights risk to residents in care.

Official plan of correction

Plan of Correction POC Licensee agrees to submit LIC200, LIC 9054, facility sketch and 610D by POC due date 03/15/24. Civil Penalties issued.

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

Official classification

Type A

Official code

87633(a)(4)

Regulation authority

CCR

What the official deficiency says

87633 Hospice Care of Terminally Ill Residents (a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician...who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility when all of the following conditions are met: (4) A written hospice care plan which specifies the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the facility is developed for each terminally ill resident or prospective resident by that resident’s hospice agency and agreed to by the licensee and the resident, or prospective resident, or the resident’s or prospective resident’s Health Care Surrogate Decision Maker, if any, prior to the initiation of hospice services in the facility for that resident, and all hospice care plans are fully implemented by the licensee and by the hospice(s). This requirement was not met as evidenced by LPAs records review and interview with Administrator. There are no hospice care plans in resident files. If not corrected, this poses an immediate Health and Safety risk to residents in care.

Official plan of correction

Administrator will submit Hospice Care plan for Resident R1 by POC date of 03/15/24. Hospice agency deliverd the hospice care plan for R2 during LPAs visit.

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

Official classification

Type A

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself Postural supports may be used under the following conditions. (5) Under no circumstances shall postural supports include ...(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 was not as evidenced by LPAs observation of records. There is no order in Resident R1's file for full bed rails. If not corrected, this poses an immediate Health and Safety risk to residents in care.

Official plan of correction

Administrator will submit Hospice Care plans for Resident R1 that includes order for full bed rails. Resident R2 by POC date of 03/15/14.

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

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

(4) The licensee shall assist residents with self-administered medications as needed. 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 R1 showing a start date of a medication on 2/8/23 and a pill bottle count of 30 which is prescribed to be administered daily and shows not given for March, April and May of 2023 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/31/2023 Plan of Correction Plan of Correction Licensee agrees to submit medication training on administration and logging medication which will include an agenda, qualified presenter and staff signatures by POC due date 5/31/23.

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 and record review, the licensee did not comply with the section cited above in not logging a medication for R1 since 2/8/23 which only shows a pill count of 30 and should be administered daily which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/31/2023 Plan of Correction Plan of correction Licensee agrees to submit an understanding of this regulation and how the regulation will be met by POC due date 5/31/23.