GLENDALE GARDEN CARE HOME

Official classification

Type A

Official code

87465(a)(8)

Regulation authority

CCR

What the official deficiency says

(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, record review, the Administrator did not comply with the section cited above in that the first aid kit has missing items like thermometer, tweezers, manual, adhesive tape, etc. Additionally, the kit contained expired BENDARYL itch stopping cream and NEOSPORIN antibiotic pain relieving cream, both creams expired on 05/2021 which poses an immediate health, safety or personal rights risk toresidents in care.

Official plan of correction

POC Due Date: 09/18/2023 Plan of Correction Administrator shall purchase a First Aid kit with current Manual and submit picture proof to CCL/LPA by POC due date.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

(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: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, record review, the Administrator did not comply with the section cited above in which LPA reviewed two (2) of the residents (R1 & R2) medications and observed that Pravastatin Sodium (10mg) and Citalopram HBR (10mg) were prescribed to be given in the AM, but Administrator & staff administer them in the PM which poses an immediate health, safety or personal rights risk to residents in care.

Official plan of correction

POC Due Date: 09/18/2023 Plan of Correction Administrator will call the residents physicians to confirm the correct time to administer medications and contact the Pharmacy to update the physician's orders regarding the medications. 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

(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 observation, interview, record review, the Administrator did not comply with the section cited above in which one of the medications for R2 was administered but the staff did not properly document the MAR and did not indicate that the medication has been given which poses an immediate health, safety or personal rights risk to residents in care.

Official plan of correction

POC Due Date: 09/18/2023 Plan of Correction Administrator shall conduct in service training to all staff on how to properly dispense and record the residents medications. Administrator will submit a copy of the in service training signed and dated by staff members to CCL/LPA by POC due date.

Official classification

Type A

Official code

87618(b)(3)(A)

Regulation authority

CCR

What the official deficiency says

(3) Ensuring that the use of oxygen equipment meets the following requirements: (A) A report shall be made in writing to the local fire jurisdiction that oxygen is in use at the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, record review, the Administrator did not comply with the section cited above in which Administrator stated that she has not written a report to the local fire department regarding oxygen use in the facility which poses an immediate health, safety or personal rights risk to residents in care.

Official plan of correction

POC Due Date: 09/18/2023 Plan of Correction Administrator agreed to contact the local fire department and make a written report regarding oxygen use in the facility. Administrator will submit proof of correction to CCL/LPA by POC due date.

Official classification

Type B

Official code

87470(c)

Regulation authority

CCR

What the official deficiency says

(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, record review, the Administrator did not comply with the section cited above in which the facility has not developed and submitted the infection control plan to CCLD which poses/posed a potential health, safety or personal rights risk to residents in care.

Official plan of correction

POC Due Date: 09/29/2023 Plan of Correction Administrator agreed to develop and submit the required infection control plan to CCL/LPA by POC due date.

Official classification

Type B

Official code

87208(a)

Regulation authority

CCR

What the official deficiency says

(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on interview, record review, the Administrator did not comply with the section cited above in which the Administrator cannot find and provide the plan of operation to LPA for review which poses/posed a potential health, safety or personal rights risk to residents in care. which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/29/2023 Plan of Correction Administrator will ensure that the plan of operation is filed in the facility and will submit a copy to CCL/LPA by POC due date.

Official classification

Type B

Official code

1569.695(a)

Regulation authority

HSC

What the official deficiency says

(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on interview, record review, the Administrator did not comply with the section cited above in that the Administrator cannot provide LPA a copy of the Emergency and Disaster plan for review which poses/posed a potential health, safety or personal rights risk to residents in care.

Official plan of correction

POC Due Date: 09/29/2023 Plan of Correction Administrator agreed to update the Emergency and Disaster plan and submit a copy to CCL/LPA by POC due date.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview, record review, the Administrator did not comply with the section cited above in that the Administrator cannot provide proof that fire and disaster drill has been conducted in the facility which poses/posed a potential health, safety or personal rights risk to residents in care.

Official plan of correction

POC Due Date: 09/29/2023 Plan of Correction Administrator will ensure that fire and emergency drill is conducted on a quarterly basis. Administrator agreed to conduct a fire and emergency drill to staff and residents as soon as possible and submit proof of in service training, signed and dated by staff members to CCL/LPA by POC due date.

Official classification

Type B

Official code

87618(b)(5)

Regulation authority

CCR

What the official deficiency says

(5) Ensuring that facility staff have knowledge of, and ability in the operation of the oxygen equipment. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, record review, the Administrator did not comply with the section cited above in that the Administrator stated that staff have not received training regarding operation of the oxygen equipment which poses/posed a potential health, safety or personal rights risk to residents in care.

Official plan of correction

POC Due Date: 09/29/2023 Plan of Correction Administrator will ensure that staff have knowledge and ability in the operation of the oxygen equipment. Administrator will scheudle training for all staff members in the operation of the oxygen equipment. Administrator will submit proof of correction to CCL/LPA by POC due date.

Official classification

Type B

Official code

87705(c)(7)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (7) An activity program shall address the needs and limitations of residents with dementia and include large motor activities and perceptual and sensory stimulation. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview, record review, the Administrator did not comply with the section cited above in which the Administrator did not have planned activities in place for residents which poses/posed a potential health, safety or personal rights risk to residents in care.

Official plan of correction

POC Due Date: 09/29/2023 Plan of Correction Administrator will ensure that activities address the needs and limitations of resident with dementia and shall develop planned activities for residents and submit proof to CCL/LPA by POC due date.

Official classification

Type A

Official code

87468.2(a)(21)

Regulation authority

CCR

What the official deficiency says

87468.2(a)(21) Additional Personal Rights of Residents in Privately Operating Facilities:(a) ... residents in... residential care facilities ... shall have all of the following personal rights: (21) To consent to have their relatives ...visit during reasonable hours, privately, and without prior notice. This requirement is not met as evidence by: Based on document review licensee did not ensure to allow visitor for R1, while R1 was on hospice which poses an immediate health, safety, or personal rights risk for persons in care.

Official plan of correction

Administrator will certify in LIC9098 that will follow recommended guidelines regarding visitation by Community Care Licensing, or Department of Public Health and will submit certification by POC due date 5/30/22.

Deadline recorded: May 30, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(19)

Regulation authority

CCR

What the official deficiency says

87468.2(a)(19) Additional Personal Rights of Residents in Privately Operating Facilities:(a) ... residents in... residential care facilities ... shall have all of the following personal rights: (19) To ....purchase photocopies of their records. Photocopied records shall be provided within two (2) business days... This requirement is not met as evidence by: Based on document review licensee did not ensure POA responsible party for R1 received a copy of R1's file which poses a potential health, safety, or personal rights risk to persons in care.

Official plan of correction

Administrator is to provide a copy of R1's file to responsible party listed on POA by 5/30/22 and submit a copy of acknowlegment of receipt by POC due date 6/3/22 to the department.

Deadline recorded: Jun 3, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation... This requirement is not met as evidence by: Based on documents reviewed and interviews R5 was not observed for change in condition on 7/24/21 which poses an immediate health, safety, or personal rights violation for residents in care.

Official plan of correction

Licensee will certify by LIC 9098 by 11/17/21 to ensure change in condition of all residents is observed, and will provide in service training to staff and submit documentation by 11//1921.

Deadline recorded: Nov 17, 2021. A deadline is not proof that correction was completed.