BURLINGTON, THE

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: Deficient Practice Statement Based on observation, records reviewed, and interview conducted, R1 is on hospice care was observed laying in bed using a hospital bed with full rail with doctor’s order for half rail bed, which poses/posed a potential health and safety and personal rights risk to the resident in care.

Official plan of correction

POC Due Date: 10/22/2025 Plan of Correction Administrator stated will obtain doctor orders for R1 who’s currently receiving hospice care that specific the need for full bed rails and submitted to the Fresno CCL by POC due date. If doctor do not indicate the need for full rail bed, full rails are to be removed by POC due date 10/22/25.

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 observation and records reviewed, R2 was observed laying in hospital bed with half rails up. There is no doctor’s order for half rail bed for R2, which poses/posed a potential health and safety and personal rights risk to the resident in care.

Official plan of correction

POC Due Date: 10/22/2025 Plan of Correction Administrator will obtain doctor orders for R2 indicating the need for half bed rail if physician indicates the need for half bed rail or Half rails will be removed by POC due date 10/22/25.

Official classification

Type B

Official code

87465(h)(6)

Regulation authority

CCR

What the official deficiency says

87465 (h)(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: This requirement is not met as evidenced by: Deficient Practice Statement Based on interview conducted, observation, and records reviewed, LPA, A1 and S1 observed R3’s medication Spiriva Respimat inhaler filled on 09/24/25 and medication Levocetirizine filled on 10/09/25 not record in Centrally Stored Medication (Lic 622) record, poses/posed a potential health and safety and personal rights risk to the resident in care.

Official plan of correction

POC Due Date: 10/17/2025 Plan of Correction Staff immediately recorded all R2’s medication into centrally stored medication list during visit. POC cleared during visit.

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 interviews conducted, observation and records reviewed, R1 is not on hospice care was observed lying bed using a hospital bed with full rail 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

Full bed rails are prohibited. Full rail will be removed by POC due date. If the resident needs a half rail, resident will be assessed and Licensee shall obtain doctor orders for R1 that specific the need for half bed rails and submitted to the Fresno CCL by POC due date 05/30/25.

Deadline recorded: May 30, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(8)

Regulation authority

CCR

What the official deficiency says

87468.2 (a)(8) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement is not met as evidenced by: Based on interviews conducted, S1 and R1 had a verbal altercation after R1 continuously squirt S1 with a water gun which poses an immediate health and safety risks to persons in care.

Official plan of correction

S1 will be retrained in in-service training on Personal rights and copies of training will be submitted to Fresno CCL by POC due date 05/15/25.

Deadline recorded: May 15, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

87705 (f)(1) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). 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 Licensee observed at approximately 1:35PM, a shovel placed against the facility wall outside room 6 patio. At approximately 1:48PM, LPA and L1 observed a tool set and automatic screwdriver stored in between the kitchen counter unlock accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/18/2024 Plan of Correction Licensee immediately removed the shovel, tool set, and automatic screwdriver and stored it in locked detached building. POC cleared during visit.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303(a) 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 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 at approximately 1:50PM, a hole in the wall under kitchen sink, which poses a potential health, safety or personal rights risk to person in care.

Official plan of correction

POC Due Date: 11/01/2024 Plan of Correction Wall under kitchen sink shall be repair and proof of repaired shall be submitted to the department by POC due date 11/01/24.

Official classification

Type A

Official code

87468(a)(1)

Regulation authority

CCR

What the official deficiency says

Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met: Based on interviews conducted, it was confirmed, S1 called R1 inappropriate names and did not speak to residents at the facility in an appropriate manner when approaching residents which poses an immediately health and safety and personal rights risk to the person in care.

Official plan of correction

S1 shall have in-service training on personal rights. Training materials and proof of staff attendance shall be submitted to the department by POC due date 07/18/24.

Deadline recorded: Jul 18, 2024. A deadline is not proof that correction was completed.