COGSWELL GARDEN HOME

Official classification

Type B

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record. 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 1 out of 7 resident files reviewed did not contain a medical assessment which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/27/2026 Plan of Correction Administrator will submit to LPA a medical assement completed by a physician which will include ambulatory status and TB clearance for R1 by POC due date.

Official classification

Type B

Official code

87555(b)(7)

Regulation authority

CCR

What the official deficiency says

General Food Service Requirements (b) The following food service requirements shall apply: Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement was not met as evidenced by: Review of Corrective Action Plan, and interviews conducted the facility did not follow a PKU diet, did not implement IPP and did not review IPP prior to placement for C 1 and C 2 which poses a potential health and safety risk for clients in care.

Official plan of correction

Administrator will conduct training for all staff which covers reviewing IPP's and reviewing PKU diets. Log of those who attended will be submitted to Licensing by POC due date. Deficiency cleared on 02/02/24 Facility complied

Deadline recorded: Feb 2, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87457(c)(4)

Regulation authority

CCR

What the official deficiency says

Pre-Admission Appraisal - General Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. If a needs assessment has already been completed by a placement agency or consultant, this shall be obtained and included in the facility's appraisal. This requirement was not met as evidenced by: The facility did not implement the IPP and did not complete a pre admission appraisal that contains the required information which poses a potential health and safety risk for clients in care.

Official plan of correction

Facility complied with the IPP and did complete a pre admission appraisal that contains the required information by POC due date. Administrator complied with Corrective Action Plan on 02/22/24 from Regional Center which included the above requirements. Deficiency cleared.

Deadline recorded: Mar 4, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(7)

Regulation authority

CCR

What the official deficiency says

General Food Service Requirements (b) The following food service requirements shall apply: Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement was not met as evidenced by: Review of Corrective Action Plan, and interviews conducted the facility did not follow a PKU diet, did not implement IPP and did not review IPP prior to placement for C 1 and C 2 which poses a potential health and safety risk for clients in care.

Official plan of correction

Administrator will conduct training for all staff which covers reviewing IPP's and reviewing PKU diets. Log of those who attended will be submitted to Licensing by POC due date. Deficiency cleared on 02/02/24 Facility complied

Deadline recorded: Feb 2, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87457(c)(4)

Regulation authority

CCR

What the official deficiency says

Pre-Admission Appraisal - General Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. If a needs assessment has already been completed by a placement agency or consultant, this shall be obtained and included in the facility's appraisal. This requirement was not met as evidenced by: The facility did not implement the IPP and did not complete a pre admission appraisal that contains the required information which poses a potential health and safety risk for clients in care.

Official plan of correction

Facility complied with the IPP and did complete a pre admission appraisal that contains the required information by POC due date. Administrator complied with Corrective Action Plan on 02/22/24 from Regional Center which included the above requirements. Deficiency cleared.

Deadline recorded: Mar 4, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities Residents in all residential care facilities for the elderly shall have all of the following personal rights: to be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: review of Corrective Action Plan, and interviews conducted the facility did not follow a PKU diet, did not implement IPP and did not review IPP prior to placement for C 1 and C 2 which poses a potential health and safety risk for clients in care.

Official plan of correction

Administrator will conduct training for all staff which covers reviewing IPP's and reviewing PKU diets. Log of those who attended will be submitted to Licensing by POC due date.

Deadline recorded: Feb 2, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87219(a)

Regulation authority

CCR

What the official deficiency says

(a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include: This requirement is not met as evidenced by: Deficient Practice Statement Based on (interview), the licensee did not comply with the section cited above in 3 out of 3 clients stated there are no activities which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/19/2023 Plan of Correction Administrator to submit monthly activity schedule by POC due date.

Official classification

Type A

Official code

87609(b)(2)

Regulation authority

CCR

What the official deficiency says

Allowable Health Conditions and the Use of Home Health Agencies. Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: The licensee provides the supporting care and supervision needed to meet the needs of the resident receiving home health care. This requirement is not being met as evidenced by: R1 was admitted to Los Angeles Community Hospital on 3/3/21 and diagnosed with six pressure injuries in different wound areas, including some that were stage four. Each pressure injury was identified as older and appeared to have developed prior to R1’s admission to LACH, on 3/3/21. Records from Outreach Home Health (OHH) show that as early as December 23, 2020, OHH noted a stage four pressure wound on R1's right buttock area. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator will review Title 22 Regulations Section 87609 on Allowable Health Conditions and the Use of Home Health Agencies and develop a written Plan of Correction (POC) to ensure compliance. Written POC must be submitted to CCL by the POC due date. ***An immediate civil penalty is being assessed in the amount of $500.00.***

Deadline recorded: Aug 16, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87615(a)(1)

Regulation authority

CCR

What the official deficiency says

Prohibited Health Conditions. Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: Stage 3 and 4 pressure injuries. This requirement is not being met as evidenced by: Records from Outreach Home Health (OHH) show that as early as 12/23/20, OHH noted a stage four pressure wound on R1's right buttock area but yet R1 continued to reside at the facility until being hospitalized on 3/3/21. The former House Manager acknowledged of knowing the extent of R1's injury and failed to obtain medical treatment because he forgot. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator will review Title 22 Regulations, Section 87615 on Prohibited Health Conditions, and conduct an in-service training with all staff and submit a copy of the sign in sheet of all attendees along with the topics covered during the in-service training to CCL, by the POC due date.

Deadline recorded: Aug 16, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(2)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care. The licensee shall provide assistance in meeting necessary medical and dental needs. This requirement is not being met as evidenced by: Records from Outreach Home Health (OHH) show that as early as 12/23/20, OHH noted a stage four pressure wound on R1's right buttock area but yet R1 continued to reside at the facility until being hospitalized on 3/3/21. This was likely due to lack of observation, documentation by facility staff and the lack of communication between staff, the treating physician and the Nurse from OHH. Staff acknowledged fault for failing to seek timely medical care for R1. The former House Manager acknowledged of knowing the extent of R1's injury and failed to obtain medical treatment because he forgot. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator will review Title 22 Regulations Section 87465 on Incidental Medical and Dental Care and develop a written Plan of Correction (POC) to ensure compliance. Written POC must be submitted to CCL by the POC due date.

Deadline recorded: Aug 16, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions. This requirement is not being met as evidenced by: On 8/15/23, LPA reviewed medications/Medication Administration Record (MAR) for Resident 4 (R4) and discovered that the Thick-It Powder (PRN) for R4 was missing at the facility. According to the Current House Manager, staff are administering Resident 5's (R5's) Thick-It Powder to R4 because R4's Thick-It Powder " ran out " . This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator will review Title 22 Regulations, Section 87465 on Incidental Medical and Dental Care, and conduct an in-service training with all staff and submit a copy of the sign in sheet of all attendees along with the topics covered during the in-service training to CCL, by the POC due date. Administrator will also order a Thick-It Powder (PRN) for R4 and submit proof of correction to CCL by the POC due date.

Deadline recorded: Aug 16, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(B)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement is not being met as evidenced by: Investigator / Dennis Seng conducted an interview with the Administrator and the Administrator admitted that facility staff failed to report the hospitalization and pressure injuries involving R1 to CCL. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator will review Title 22 Regulations, Section 87211 on Reporting Requirements, and conduct an in-service training with all staff and submit a copy of the sign in sheet of all attendees along with the topics covered during the in-service training to CCL, by the POC due date.

Deadline recorded: Aug 31, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(d)(1-6)

Regulation authority

CCR

What the official deficiency says

Personnel Requirements - General. All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance... This requirement is not being met as evidenced by: Staff and facility Registered Nurse (RN) / Nelia Aquino stated that there were no formal trainings conducted for Cogswell Garden Home staff to care and treat for the pressure injuries sustained on R1 and any other residents until after the incident involving R1. Staff acknowledged not being aware that facility could not care for residents with stage three or four pressure injuries due to lack of training. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator will review Title 22 Regulations Section 87411 on Personnel Requirements - General, and develop a written Plan of Correction (POC) to ensure compliance. Written POC must be submitted to CCL by the POC due date.

Deadline recorded: Aug 31, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87611(b)(1)(A-D)

Regulation authority

CCR

What the official deficiency says

General Requirements for Allowable Health Conditions. The licensee shall complete and maintain a current, written record of care for each resident that includes, but is not limited to, the following: Documentation from the physician of the following: (A) Stability of the medical condition(s); (B) Medical condition(s) which require incidental medical services; (C) Method of intervention; (D) Resident's ability to perform the procedure; and (E) An appropriately skilled professional shall be identified who will perform the procedure if the resident needs assistance. This requirement is not being met as evidenced by: During the course of this investigation, facility staff were unable to produce records showing that there was a care plan for the R1's pressure wound (right buttock area) and if staff were following the care plan. On 8/15/23, the Current House Manager looked in the file of R1 and was unable to produce a copy of a care plan for R1. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator will review Title 22 Regulations Section 87611 on General Requirements for Allowable Health Conditions, and develop a written Plan of Correction (POC) to ensure compliance. Written POC must be submitted to CCL by the POC due date.

Deadline recorded: Aug 31, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(b)(13)

Regulation authority

CCR

What the official deficiency says

Resident Records. Each resident’s record shall contain at least the following information: Continuing record of any illness, injury, or medical or dental care, when it impacts the resident's ability to function or needed services. This requirement is not being met as evidenced by: R1 was receiving wound care from OHH once per week. The facility did not maintain adequate records for R1. Client Notes prepared by staff dated 2/24/21, stated that “they told us to reposition him from time to time” but there was no documentation in R1's file regarding repositioning the resident. Staff interviewed stated that R1 was given a bath once every three days and staff only conducted body checks on R1 during bathing. Again, there was no documentation in R1's file regarding staff conducting body checks. Staff interviewed stated that logs were not kept for body checks or repositioning. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator will review Title 22 Regulations Section 87506 on Resident Records, and develop a written Plan of Correction (POC) to ensure compliance. Written POC must be submitted to CCL by the POC due date.

Deadline recorded: Aug 31, 2023. A deadline is not proof that correction was completed.