STARLIGHT FACILITY INC.

Official classification

Type B

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 and record review, the licensee did not comply with the section cited above as one resident's bed was observed to fontain full bed rails which posed a potential personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/04/2026 Plan of Correction Administrator removed the bed rails at the time of the visit. POC cleared.

Official classification

Type B

Official code

87465(h)(6)

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: 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 three (3) resident’s CSMDRs had medications quantity and strength improperly documented, one CSMDR contained inaccurate administration instructions for one (1) medication and one (1) additional medication was not logged on the CSMDR which posed a potential health risk to persons in care.

Official plan of correction

POC Due Date: 02/04/2026 Plan of Correction Administrator corrected and re-printed the CSMDRs at the timme of the visit. POC cleared.

Official classification

Type B

Official code

87218(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153. (1) The initial personal property inventory shall be completed by the licensee and the resident or the resident's representative. 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 one resident was identified as not having an initial personal property inventory completed at the time of admission which poses a potentia personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/18/2025 Plan of Correction Licensee will submit a completed personal property inventory to CCL no later than POC due date.

Official classification

Type B

Official code

87457(c)

Regulation authority

CCR

What the official deficiency says

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. 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 the pre-admission appraisal for one identified resident was not completed prior to admission to the facility which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/18/2025 Plan of Correction Licensee will submit a completed pre-admission appraisal and appraisal needs and services plan for the identified resident to CCL no later than POC due date.

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 as one identified resident's file did not contain proof of a negative TB test which poses a potential health risk to persons in care.

Official plan of correction

POC Due Date: 02/18/2025 Plan of Correction Licensee will submit proof of a negative TB test for the identified resident to CCL no later than POC due date.

Official classification

Type B

Official code

87507(c)

Regulation authority

CCR

What the official deficiency says

(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited aboveas one resident's admission agreement was not signed within 7 days of residing at the facility which posed a potential personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/04/2025 Plan of Correction Administrator and resident signed the admission agreement at the time of the visit. POC cleared.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

87465(c)(2) Incidental and Medical Care: ....Once ordered by the physician the medication is given according to the physician's directions. This requirement has not been met as evidenced by: Based on interviews and medication audit, the licensee did not comply with the section cited above as R1 did not receive 1 of their medications as prescribed and did not receive 2 of their medications in one occassion,which poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee agreed to review section cited and provide a statement of understanding as well as a plan to ensure how they ensure that residents will be provided medications as prescribed and send to LPA via email by COB 1/3/2025.

Deadline recorded: Jan 3, 2025. A deadline is not proof that correction was completed.