LA POSADA IN GLENDORA

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above two restrooms did not have the required tempreature bathroom #1 126.6, and bathroom #2 95.2 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/17/2025 Plan of Correction Assistant Administrator will adjust water and send LPA picture. A water log will be created for one week and sent to LPA by POC due date.

Official classification

Type A

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

(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, the licensee did not comply with the section cited above in three (3) out of five (5) residents have full bed rails and are not on hospice care which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/17/2025 Plan of Correction Assistant Administrator will remove bed raild and send LPA picture by POC due date.

Official classification

Type B

Official code

87412(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: 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 Administrator file was not present during visit which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/23/2025 Plan of Correction Assistant Administrator will obtain file and email LPA by POC due date.

Official classification

Type B

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 record review, the licensee did not comply with the section cited above three (3) residents were missing medication listed on MAR log which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/23/2025 Plan of Correction Assistant Administrator will obtain DC from pharmacy .R1 missing Dextrose inj 50% 50 ML as needed. R2 missing Quetiapine tab 25 MG PRN. R3 missing Docusate 100 MG 2xday.

Official classification

Type B

Official code

87458(c)(1)(A)

Regulation authority

CCR

What the official deficiency says

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis. 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 two residents did not have TB results on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/23/2025 Plan of Correction Assistant Administrator will send LPA TB results 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 record review, the licensee did not comply with the section cited above facility did not have and drills to review which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/23/2025 Plan of Correction Assistant Administrator will conduct drills with staff and send to LPA by POC due date.

Official classification

Type A

Official code

87705(d)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (d) The licensee shall ensure that the facility has an auditory device... alert feature to monitor exits on exterior doors ... accessible to those residents who may be at risk for elopement... This requirement is not met as evidenced by: Based on LPAs observation and record review, the licensee did not comply with the section cited above in four (4) out six (6) residents with dementia who had access to the main entrance door and there was no operable auditory device which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Facility will fix auditory device by changing battery. Deficiency was fixed during visit and it was tested. Auditory device is now functioning properly.

Deadline recorded: May 10, 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 Care of Persons with Dementia (f) 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: Based LPAs observations, the licensee did not comply with the section cited above in that the desinfectant, knives and sharps were accessible to residents with Dementia and stored in the garage, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Facility will secured sharps and desinfectant in a secured room at the garage. Administrator moved sharps and desinfectant inside a locked room within the garage. Deficiency was clear at time of visit

Deadline recorded: May 10, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105-degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by: Based LPA observation, the licensee did not comply with the section cited above as hot water temperature in resident’s bathroom measured at 124.1- and 124.5-degrees F during today’s visit, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Maintenance staff will regulate water temperature tank today. Facility will monitor water temperature for 3 days to ensure water temperature is within Title 22 regulation, and will send water temperature log to CCLD by 5/13/25.

Deadline recorded: May 10, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87204(a)

Regulation authority

CCR

What the official deficiency says

Capacity and Ambulatory Status 87204(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. This requirement is not met as evidenced by: The facility has approved two (2) hospice waivers on file but the Licensee retained three (3) hospice residents at the facility since 8/13/24. Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/06/2024 Plan of Correction Licensee agreed to submit a request for hospice waiver increase to a total of three (3) or apply an exception for the one individual who admitted to hospice on 8/13/24 by the POC due date.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review… shall prior to working… in a licensed facility: (2) Request a transfer of a criminal record clearance… This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 of 2 staff having a criminal background clearance, but not associated to the facility, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/03/2022 Plan of Correction The licensee will associate the staff in question via Guardian and provide a copy of the facility association list as proof of association, via email to LPA by the POC due date: 09/03/22.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (e) Water supplies… shall be maintained as follows: (2) Faucets used by residents for personal care… shall deliver hot water. Hot water temperature controls shall be maintained… to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). (5) Non-skid mats or strips shall be used in all bathtubs and showers. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interviews, the licensee did not comply with the section cited above in 2 of 2 bathroom sinks which water temperature measured at 144.2*F and 141.4*F. LPA also observed that 2 of 2 showers were missing non-skid mats. Staff explained none were available at the facility, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/03/2022 Plan of Correction Licensee will lower the temperature on the water heater and measure it to ensure it measures within 105*F-120*F to be in compliance. A log of the water temperature will also be completed and provided to LPA for the following 5 days to ensure the water temperature is maintained. Non-skid mats/strips will be purchased and a picture of them installed, along with a copy of the receipts will be provided to LPA by the POC due date: 09/03/22.

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives… that could constitute a danger to the resident(s). (2) … toxic substances such as… cleaning supplies and disinfectants. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above in 1 kitchen knife left out on top of the counter next to the kitchen sink, accessilbe to persons in care. And floor cleaning soution was left unattended in one of the resident's rooms, accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/03/2022 Plan of Correction The staff that assisted with the visit immediately put away the knife and the cleaning supplies, making them inaccessible to persons in care. This deificiency has been cleared.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (c)Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 resident with dementia did not have an updated medical assessment or reappraisal (last one was 08/26/19) which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/16/2022 Plan of Correction Licensee has agreed to have a medical assessment and reappraisal completed for dementia residents and have it available in their file. A copy of the updated records will be emailed to LPA by the POC due date: 09/16/22.

Official classification

Type B

Official code

87465(e)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (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 residents file... This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and record review, the licensee did not comply with the section cited above in 2 residents not having a written order from a physician in their file for the medications they are currently taking, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/16/2022 Plan of Correction The licensee has agreed to contact the resident's primary care physician's to obtain the written orders for the medications the residents are currently taking. A copy of the written orders will be emailed to LPA by the POC due date: 09/16/22.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 of 6 resident's files were not readily available at the facility for LPA to review, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/16/2022 Plan of Correction Licensee has agreed to bring the resident's file to the facility and maintain it there. A copy of the resident's complete file will also be emailed to LPA by the POC due date.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by: Deficient Practice Statement Based on observations and records reviewed, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. Routine symptom screening (+/- temperature and symptom check) has been initiated at entry for all staff, residents, and visitors. This practice has a health and safety impact that includes, but is not limited to personal rights, health-related services, responsibility for providing care and supervision, and personnel requirements. LPA's and visitors were not screened during annual visits conducted on 9/10/21 and 9/15/21.

Official plan of correction

POC Due Date: 09/22/2021 Plan of Correction Administrator will provide training to staff regarding routine symptom screening for all visitors. Proof of training will be submitted by 9/22/21.

Official classification

Type B

Official code

87465(h)(6)(A-F)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by:(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. Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above in 5 out of 6 residents which poses a potential health, safety or personal rights risk to persons in care. Resident #3's (R3) record did not include Quetiapine Fumarate 50 mg and Simvastatin 20 mg medication. Resident #2's (R2) record did not include Hydrocodone 325 mg and Escitalopram 20 mg medication. Resident #4 (R4), Resident #5 (R5), Resident #6 (R6) did not have a list of medications, but had medication present in the facility.

Official plan of correction

POC Due Date: 09/29/2021 Plan of Correction Administrator will correct R2 and R3 medication records. Administrator will obtain a medication list for R4, R5, and R6. Medication records will be submitted by 9/29/21.