NOHO ASSISTED LIVING, INC

Official classification

Type B

Official code

87618(b)(3)(A)

Regulation authority

CCR

What the official deficiency says

Oxygen Administration - Gas and Liquid: In addition to Section 87611(b), the licensee shall be responsible for the following: Ensuring that the use of oxygen equipment meets the following requirements: A report shall be made in writing to the local fire jurisdiction that oxygen is in use at the facility. This requirement was not as evidenced by: Resident #1 uses oxygen and it was not reported to the local fire department as of today's visit

Official plan of correction

Licensee will submit written notification to the local fire department of oxygen being used at the facility. A copy of the notification letter will be provided to the Department as evidence that the local fire department was notified by 11/25/24.

Deadline recorded: Nov 25, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87632(d)(2)

Regulation authority

CCR

What the official deficiency says

Hospice Care Waiver: If the Department grants a hospice care waiver it shall stipulate terms and conditions of the waiver as necessary to ensure the well-being of terminally ill residents and of all other facility residents, which shall include, but not be limited to, the following requirements: The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of admission to the facility and the name and address of the hospice. Resident #1 was receiving hospice services begining 11/8/24 and it was not reported to the Department

Official plan of correction

Licensee will submit an hospice initiation letter to the Department for all residents who are placed on hospice within 5 days of initiation. Licensee will submit a hospice initiation letter with the name of the resident, date of initiation, name of the hospice agency and address and telephone number by 11/25/24

Deadline recorded: Nov 25, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(g)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care: The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement was not met as evidenced by: Resident #1 was observed having difficulty breathing before lunch and the staff did not call 911 services until the late afternoon when the resident's ability to breathe rapidly declined.

Official plan of correction

Licensee will review their emergency protocol and draft a written plan of action that will be implemented to ensure that all residents are provided with immediate emergency services by 11/19/24 Licensee will also provide staff with personal rights training and submit evidence of training by 11/25/24.

Deadline recorded: Nov 19, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(d)(7)

Regulation authority

CCR

What the official deficiency says

(7) Fireplaces and open-faced heaters shall be adequately screened. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as the fire place was observed with a sliding glass door and did not have a fire screen placed in front to make the fire place inaccessible to the 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: 08/29/2023 Plan of Correction The Licensee will purchase a fire screen and place in front of the fire place so that there is no direct access to the fire place by 8/29/23

Official classification

Type B

Official code

87465(d)(1)

Regulation authority

CCR

What the official deficiency says

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to 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: (1) Facility staff shall contact the resident's physician prior to each dose, describe the resident's symptoms, and receive direction to assist the resident in self-administration of that dose of medication. 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 4 out of 5 files reviewed, the facility has not obtained PRN Authorization letters for Resident # 1, Resident #2, Resident #4 and Resident #5 to determine if the residents are capable of making their need for the medications known. The facility has been dispensing medications without contacting the physician and obtaining instructions and this poses a potential health, safety risk or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/29/2023 Plan of Correction The Licensee will contact the prescribing physicians to obtain completed PRN Authorization letters for Residents #1, #2, #4 and #5 and maintain in the residents files. A copy will also be faxed over to Licensing by 8/9/23.

Official classification

Type B

Official code

87465(d)(2)

Regulation authority

CCR

What the official deficiency says

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to 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) The date and time of each contact with the physician, and the physician's directions, shall be documented and maintained in the resident's facility 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 4 out of 5 files reviewed that the staff are dispensing PRN medications without contacting the doctor and are not documenting the physicians instructions, the results of the the medication, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/29/2023 Plan of Correction The Licensee will in addition to documenting the date and dosage that the PRN medication was dispensed, also include the results of the medication

Official classification

Type B

Official code

87465(d)(3)

Regulation authority

CCR

What the official deficiency says

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to 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) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility 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 4 out of 5 counts by not documenting the residents results of the medication which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/29/2023 Plan of Correction

Official classification

Type B

Official code

87465(e)(1-2)

Regulation authority

CCR

What the official deficiency says

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, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.(1) The specific symptoms which indicate the need for the use of the medication.(2) The exact dosage.(3) The minimum number of hours between doses.(4) The maximum number of doses allowed in each 24-hour period. 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 5 out of 5 counts of files reviewed for physician's orders for the centrally stored medications. None of the files had copies of physicians orders on file for the centrally stored medication which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/29/2023 Plan of Correction The Liicensee will contact the prescribing doctor for all centrally stored medications and obtain a copy of the doctor's written order on a prescription blank and maintain in the resident's file

Official classification

Type B

Official code

87307(3)(B)

Regulation authority

CCR

What the official deficiency says

87307 Personal Accommodations and Services. (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers 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 2 out of 3 resident bedrooms toured, bedroom #1 and bedroom #2 did not have any chest of drawers which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/29/2023 Plan of Correction The Licensee will purchase chest of drawers that meet Titlee22 requirement for bedroom #1 and bedroom #2 . Provide evidence that the chest of drawers have been purchased by 8/29/23