DOWNEY RETIREMENT CENTER

Official classification

Type A

Official code

87465(h)(3)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (3) Each container shall carry all of the information specified in (6)(A) through (E) below plus expiration date and number of refills. This requirememt was not met as evidence by: Facility failed to have a separate container with the required information on the label for residents #1 and #2.

Official plan of correction

Facility to conduct a training for all staff that assist with medication and email a copy of the training log to LPA by POC due date. (on 9/12/25 LPA received a copy of the medication training log, training was conducted on 9/9/25).During todays visit LPA reviewed PRN medications for R1-R3, all PRN's were accounted for with proper lables and listed on the eMAR. POC is cleared no further action is needed.

Deadline recorded: Feb 7, 2026. 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

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirememt was not met as evidence by: Facility failed to obtain a Discontinue Order and centrally store R1 and R3’s PRN medications.

Official plan of correction

Facility to conduct a training for all staff that assist with medication and email a copy of the training log to LPA by POC due date (on 9/12/25 LPA received a copy of the medication training log, training was conducted on 9/9/25).During todays visit LPA reviewed PRN medications for R1-R3, all PRN's were accounted for with proper lables and listed on the eMAR. POC is cleared no further action is needed.

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

Official classification

Type B

Official code

87465(h)(6)(A-E)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (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: (A) The name of the resident for whom prescribed. (B) The name of the prescribing physician. (C) The drug name, strength and quantity. (D) The date filled. (E) The prescription number and the name of the issuing pharmacy. (F) Instructions, if any, regarding control and custody of the medication. This requirememt was not met as evidence by: Facility failed to list R1 and R2’s medication on the eMAR

Official plan of correction

Facility to conduct a training for all staff that assist with medication and email a copy of the training log to LPA by POC due date (on 9/12/25 LPA received a copy of the medication training log, training was conducted on 9/9/25). During todays visit LPA reviewed PRN medications for R1-R3, all PRN's were accounted for with proper lables and listed on the eMAR. POC is cleared no further action is needed.

Deadline recorded: Feb 20, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(e)

Regulation authority

CCR

What the official deficiency says

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. This requirement is not met as evidenced by: Deficient Practice Statement Based on medication review, the licensee did not comply with the section cited above as LPA found that there were missing medications for 3 out of 10 residents during medication review. which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/29/2025 Plan of Correction Administrator/Licensee to provide proof that medication is on order for the residents missing medications via email by POC due date (LPA emailed a list of resident names and missing medications to Administrator and created an 812 with information). To clear POC LPA is asking that there be an staff training on medication (for staff that assist with medication) and email a copy of the training log participant list with signatures to LPA by 9/12/25.

Official classification

Type B

Official code

87463(i)

Regulation authority

CCR

What the official deficiency says

(i) When there is significant change in condition, as defined in Section 87101, Definitions, or once every 12 months, whichever occurs first, the licensee shall arrange an in-person or virtual meeting or conference call to share the reappraisal with the resident, the resident's representative, if applicable, and appropriate facility staff, as specified in Section 87467, Resident Participation in Decision Making. 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 during record review LPA observed 4 resident files that were missing their yearly reappraisal, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/12/2025 Plan of Correction Administrator/Licensee to email a copy of the updated reappraisal/needs and service plan to LPA by POC due date. (LPA provided a list of names to Administrator via email for residents that are missing their reappraisals)

Official classification

Type B

Official code

87412(c)(2)(D)

Regulation authority

CCR

What the official deficiency says

(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.(2)Documentation of staff training shall include: (D) Number of training hours per subject. This requirement was not met as evidenced by: documentation of staff training records did not reflect number of training hours per subject. This poses a potiential health, safety, or Personal Rights risk to persons in care.

Official plan of correction

*NO FURTHER ACTION REQUIRED. POC CLEARED on 8/12/25* Administrator Mendibles emailed plan that outlines steps the facility will take to ensure staff training hours are documented according to regulations noted in Title 22. Email was received 7/3/25.

Deadline recorded: Aug 12, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87618(b)(3)(B)

Regulation authority

CCR

What the official deficiency says

Oxygen Administration - Gas and Liquid. (3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas. This requirement is not met as evidenced by: Based on observation, resident room 109 has an oxygen tank in the room, and a " No Smoking-Oxygen in Use " sign was not posted outside resident room door and not at appropriate areas, which poses an immediate health, safety, or personal rights risk to persons in care.

Official plan of correction

Administrator shall ensure that a No Smoking-Oxygen in Use sign is posted on resident door or appropriate areas when oxygen tanks are used inside the room. Submit picture proof that the signs are posted.

Deadline recorded: Jan 28, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) 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: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This was not met as evidence by: The Department received a Special Incident Report on 5/21/24 stating that on 5/18/24 R1 sustained injuries and was sent to the hospital after being experiencing a unwitnessed fall when S1 left R1 unattended during a shower for approximately 5 minutes. Interviews with Administrator and S1 confirmed this story as well as record review of both S1 and R1.

Official plan of correction

Licensee/Administrator to retrain all staff in assisting Residents with Activities of Daily Living (ADL's) and training on proper procedures to take when a back up caregiver assistance is needed. Copy ot the training materials along with the date trainings will be conducted, must be emailed to LPA by 6/1/21. tena.herrera@dss.ca.gov

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

Official classification

Type B

Official code

87555(a)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements: (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents... This requirement is not met as evidence by: Based on observation Licensee did not ensure staff properly stored and disposed of expired/best by food items wich poses a potential personal right, health, or safey risk to the persons in care.

Official plan of correction

Administrator will provide in-service training to kitchen staff regarding quality of food, storing, disposing, shelf life of food items, and will submit a copy of in-service training with topic, duration of training, and sign-in log by POC due date 7/14/23.

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