REGENCY PARK OAK KNOLL

Official classification

Type B

Official code

87608(a)(5)(A)

Regulation authority

CCR

What the official deficiency says

Postural Supports. A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement was not met evidenced by: Based on observation during visit conducted on 4/15/25, the bed in room 118 had a three-quarter rail. No physician order was on file or provided to LPA.This posed a potential health, safety or personal rights risk to resident in care.

Official plan of correction

Executive Director submitted picture evidence that the bed rail was removed. Per R1's physician, no bed rail order was approved by the residents doctor. *Citation is cleared. .

Deadline recorded: Jul 15, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

Postural Supports. 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: Based on observation, the bed in room 118 had a quarter/full bed rail. Resident (R1) is not presently receiving hospice care. This poses an iimmediate health, safety or personal rights risk to resident in care.

Official plan of correction

Staff shall remove R1's quarter/full bed rail. Submit self-certification and picture evidence that the rail was removed. If a half rail physician ordered is obtained submit a copy. Licensee agreed to remove a half rail from R2's bed and will submit picture proof by tomorrow that the half rail was removed.

Deadline recorded: Apr 16, 2025. 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

87465 Incidental Medical and Dental Care (g) 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... This requirement is not met as evidence by: Based on interviews conducted licensee did not ensure that staff would call 911 for R1 after sustaining a fall and complaining of pain which poses an immediate risk to the health, safety, or personal rights of the residents in care.

Official plan of correction

Administrator provided in service training regarding Emergency procedures on 6/13/24 to staff. Deficiency cleared as of 6/17/24.

Deadline recorded: Jun 18, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87217(b)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidence by: Based on observations and interviews conducted licensee did not ensure R1's room was sanitary at all times which poses a potential health, safety, or personal rights risk to the persons in care.

Official plan of correction

Administrator will provide an in-service training to maintenance and housekeeping staff regarding proper cleaning and disinfecting and response time to fecal/urine carpet cleaning by POC due date 7/2/24.

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

Official classification

Type B

Official code

87217(b)

Regulation authority

CCR

What the official deficiency says

87217 Safeguards for Resident Cash, Personal Property, and Valuables (b) Every facility shall take appropriate measures to safeguard residents'..., personal property... which have been entrusted to the licensee or facility staff. This requirement is not met as evidence by: Based on interviews and documents reviewed the licensee did not ensure that R1's wheelchair was properly listed and safe keep at the facility which poses a potential risk to the health, safety, or personal rights of the persons in care.

Official plan of correction

Administrator will certify in writing that upon admission all items will be listed, staff will be responsible to report items that may be found around the facility, and family will be notify of storage of such items by POC due date 7/2/24.

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

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. 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 8 staff, staff #3-#8 (except staff#6) do not have 20 hours of training including the topics above which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/30/2024 Plan of Correction Administrator will submit copies of training provided to staff for a total of 20 hours including the above topics to the department by POC due date 5/30/24.

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 in 4 out of 9 resident's bathrooms water temperature was tested as follow; room #246 tested at 121.1, room #223 tested at 121.2, room #231 tested at 122.1, room #104 tested at 120.2 degrees F., which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/10/2024 Plan of Correction Admininstrator will adjust water temperature and will certify in writing that will ensure water temperature is within the required 105-120 degrees F. Administrator will submit this in writing to the department by POC due date 5/10/24 and will keep a daily log for the water temperature in the above rooms for 7 days and will submit a copy to the department.

Official classification

Type B

Official code

87303(e)(5)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (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, the licensee did not comply with the section cited above in common shower does not have a skid mat/strip which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/16/2024 Plan of Correction Administrator will ensure a skid mat/strip is provided in the common shower to ensure the safety of the residents and will submit a picture to the department by POC due date 5/16/24.

Official classification

Type B

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. 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 passageway exit from the egress exit door of laundry towards the kitchen ending at the parking lot was observed blocked with laundry cart, food tray cart, and trash cans which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/16/2024 Plan of Correction Administrator will ensure passaways are clear of obstructions and will provide in-service training to staff regarding Emergency Procedures, Safety, and Evacuation will submit a copy of the log with duration of in-service, signing log, topic discuss to the department by POC due date 5/16/24.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements: (a) Each licensee shall furnish... (1) A written report shall be submitted...within seven days of the occurrence of (D) Any incident which threatens the welfare, safety or health of any resident. This requirement was not met as evidence by: Based on documents reviewed licensee did not ensure to report scabies cases to the CLLD and PDPH in a timely manner which poses a potential health, safety, or personal right risk to persons in care.

Official plan of correction

Administrator will submit unusual incident report for S1 and R1 to the department for scabies case/treatment by 6/6/23 and will ensure to report timely to PDPH.

Deadline recorded: Jun 6, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

(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 record review, the licensee did not comply with the section cited above in resident #1,#2, and #5 do not have a current medical assessesment which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/16/2023 Plan of Correction Administrator will obtain annual medical assessment for R1, R2, and R5 and will submit a copy to the department by POC due date 6/16/23.

Official classification

Type B

Official code

87608(a)(5)(A)

Regulation authority

CCR

What the official deficiency says

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. 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 in resident #2 and #5 beds were observed with half bed rails and a physician's request was not on file which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/16/2023 Plan of Correction Administrator will request physician's order and will submit a copy to the department by POC due date 6/16/23.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: (a) ... Section 87468.1, Personal Rights of Residents...(4) To care, supervision,... meet their individual needs...by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidence by: Based on documents review facility did not ensure R1 did not leave the facility unattended which is an immediate risk to the health, safety, or personal rights to the persons in care.

Official plan of correction

Licensee will provide in-service training to staff regarding wandering behaviors and steps to take prevent and after a resident has exit the facility by POC due date 11/19/22.

Deadline recorded: Nov 19, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(2)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements:(a)...licensee shall furnish...reports as the Department ...require,...:(2)Occurrences, such as epidemic outbreaks,... which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile... This requirement is not met as evidence by: Based on documents reviewed, and observation licensee failed to report CCLD, LTCO of COVID 19 cases prior 1/21/22 which poses a potential health, safety, or personal rights risk to persons in care.

Official plan of correction

Licensee will ensure to notify all pertaining agencies when an epidemic outbreak occurs, facility has implemented reporting the department since 1/21/22. Deficiency cleared on 1/26/22.

Deadline recorded: Feb 2, 2022. A deadline is not proof that correction was completed.