PRIMECARE BELLFLOWER

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as during tour LPA observed a large bottle of fabuloso (with disinfectant inside) under the sink in the client restoom (unlocked cabinet). This restroom is located between bedroom #1 and kitchen with two doors one that exits in kitchen and other door that enters bedroom. which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/21/2024 Plan of Correction **Staff Jeneffer immediatly removed disinfectant and stored with all other disinfectants in a locked cabinet** Licensee/Administrator to conduct a training that covers proper storage of disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. All staff must complete training and a copy of the training materials and participant list is to be emailed to LPA by 7/8/2024. (tena.herrera@dss.ca.gov)

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: 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 as R1's physician report indicates that resident is bedridden (resident currently resides in room #1 which is not cleared for bedridden residents), per administrator this is an error on physician report as resident is non-ambulatory not bedridden, this poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/08/2024 Plan of Correction Licensee/Administrator to forward updated physician report via email with correct ambulatory status to LPA by 7/8/2024. (tena.herrera@dss.ca.gov)

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements – General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review,, the Administrator did not comply with the section cited above in that during the staff file review staff #1 (S1) did not have a valid 1st Aid/CPR card on file which poses/posed a potential health, safety or personal rights risk to residents in care.

Official plan of correction

POC Due Date: 08/07/2023 Plan of Correction Administrator shall ensure all staff have current First Aid/CPR training on file. Administrator will submit a copy of Staff (S1) First Aid/CPR training certificate to CCL/LPA by POC due date.

Official classification

Type A

Official code

87465(c)(1)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (1) There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication, all of the information in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication when the physician should be contacted for a medication reevaluation. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the Administrator did not comply with the section cited above in that the facility staff administers PRN medications without proper label from the Pharmacy and not listed on the Physician's medication order which poses an immediate health, safety or personal rights risk to residents in care.

Official plan of correction

POC Due Date: 08/01/2023 Plan of Correction Administrator will ensure that the PRN medications have the proper pharmacy label and shall contact the residents physicians to include the PRN medications on the physicians medicaiton order list. Administrator will submit proof to CCL/LPA by POC due date.

Official classification

Type A

Official code

87465(c)(3)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the Administrator did not comply with the section cited above in that the facility staff administered eight (8) medications for Resident #1 for a.m. cycle but was not recorded on MAR properly which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/01/2023 Plan of Correction Administrator will ensure medication provided to the residents is on cycle and record properly by staff on Medication Administration Record (MAR) sheet and re-train staff on medication. Proof of training signed and dated by staff shall be submitted to CCL/LPA by POC due date.

Official classification

Type A

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities shall...:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidence by: Based on documents review, and interviews Licensee failed to ensure R1 did not sustained a subdural hematoma to the head which poses an immediate health, safety, or personal rights risk to the persons in care.

Official plan of correction

Administrator and licensee will obtain training from an outside source in procedures to ensure the safety of the resident and emergency situations, contacting 911,and will provide training to staff regarding injuries and contacting 911. Administrator will schedule training by POC due date 3/17/23 and submit training to the dept. by 3/23/23.

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

Official classification

Type A

Official code

87465(g)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care: (g) 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, but not limited to, an apparent life-threatening medical crisis... This requirement is not met as evidence by: Based on documents review, and interviews conducted Licensee failed to contact 911 in a timely manner which poses an immediate health, safety, or personal rights risk to the persons in care.

Official plan of correction

Administrator and licensee will obtain training from an outside source in procedures to ensure the safety of the resident and emergency situations, contacting 911,and will provide training to staff regarding injuries and contacting 911. Administrator will schedule training by POC due date 3/17/23 and submit training to the dept. by 3/23/23.

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

Official classification

Type B

Official code

1569.269(a)(21)

Regulation authority

HSC

What the official deficiency says

Enumerated rights; severability. Residents of residential care facilities for the elderly shall have all of the following rights: To have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided, not to exceed two business days, at a cost not to exceed the community standard for photocopies. This requirement was not met by evidence of: Based on records review resident (R1's) responsible party requested resident records on September 13, 2021. Licensee provided resident records on September 17, 2021, exceeding the 2 working days per health and safety code of regulations.

Official plan of correction

Administrator provided copies of resident (R1's) file records on September 17, 2021. A copy of the overnight receipt was provided to LPA. Deficiency is cleared.

Deadline recorded: Sep 28, 2021. A deadline is not proof that correction was completed.