PASADENA HIGHLANDS

Official classification

Type A

Official code

87555(b)(27)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. 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 rodent droppings were observed underneath the shelfing units in the corners by the walls. which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/06/2026 Plan of Correction Cleared at the time of visit. Director provided LPA with proof of scheduled pest management appointment for 1/7/25. Maintenance cleaned the areas in which the droppings were observed by LPA during today's visit. LPA, observed the area to ensure it was cleared of rodent droppings.

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) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This deficiency is evidenced by the following:' R1 pulled on pull cord several times for assistance and staff failied to enter room resulting in R! having to call 911.

Official plan of correction

Administrator will conduct training on personal rights with staff and what to do when residents call for help with pull string and send LPA training log by POC due date.

Deadline recorded: Aug 25, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(f)(4)

Regulation authority

CCR

What the official deficiency says

Basic Services. Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports. Based on record review and interviews conducted resident (R1) required repositioning, incontinence care, and feeding assistance after return from hospitalization. R1 had a change in condition due to injury sustained on 10/20/21. Assistance was not provided in a timely manner. This poses a potential health and safety risk to residents in care.

Official plan of correction

Facility shall evaluate staffing needs, re-assess resident (R1), update the Care Plan, and submit a written statement and proof of staff training. In addition, facility shall review all resident records to ensure Care Plans have been updated.

Deadline recorded: Feb 17, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

Personnel Requirements-General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met by evidence of: Based on record review and interviews conducted between October 2021- January 2022 the facility has experienced staffing shortages. Resident (R1) required total care, but was not being checked by staff as indicated in the re-assessment. This poses a potential health and safety risk to residents in care.

Official plan of correction

Administrator agrees to submit a written plan that states how the deficiency was corrected. In addition, staff shall receive training.

Deadline recorded: Feb 17, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(5)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed. This requirement is not met as evidenced by: Based on interviews conducted and record review on Jan. 1, 2022 (R1) was not administered evening medication as directed by MD. The meidications were administered late, were not crushed, and the wrong inhaler was taken to the room. Staff (S6) acknowledged medication error. This poses an immediate health and safety risk.

Official plan of correction

Administrator shall ensure all med-tech staff distribute medications as directed. Submit written proof of staff training and explain the steps taken to avoid future medication errors.

Deadline recorded: Feb 4, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

Additional Personal Rights of Residents in Privately Operated Facilities. In addition to ... Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on interviews and record review resident (R1) fell in the lobby area on 10/20/21. R1 was without assistance, but per Care Plan R1 requires escort assistance. This poses a potential Health and Safety risk to residents in care.

Official plan of correction

Director agrees to submit a written plan stating how this was corrected, and what was done. Submit proof of staff training and attach training topics.

Deadline recorded: Feb 17, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.50(a)(3)

Regulation authority

HSC

What the official deficiency says

(a)(3) Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the front desk did not comply with the section cited above in 2 of 2 counts which poses an immediate health, safety or personal rights risk to persons in care. Front dest staff did not screen for COVID-19 symptons or check temperture of LPAs when greeted at arrival to facility.

Official plan of correction

POC Due Date: 02/04/2022 Plan of Correction Administrator will address how facility will correct the screening and temperture check for visitors arriving at facility and send writen statement by POC date.

Official classification

Type A

Official code

87465(a)(5)

Regulation authority

CCR

What the official deficiency says

(5) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interviews, the facility did not comply with the section cited above for one resident in room #223 as LPA, Administrator and Nurse Laura all observed medications in resident's room which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/04/2022 Plan of Correction Facility removed the medications from the residents's room druing visit. Aministrator will conduct training for staff on medication handling and storing and will send log with staff signatures to LPA by POC date.

Official classification

Type A

Official code

87211(a)(2)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements. Within 24 hours the licensee shall notify the licensing agency (and the local health officer, if appropriate) if an epidemic outbreak, poisoning, catastrophe or major accident which threatens the welfare, safety, or health of residents, personnel or visitors occurs. Facility had outbreak of Covid -19 (first of 12 individuals tested positive on 12/25/2021 and not reported untill 01/12/2022) and did not report to health department and licensing agency as required

Official plan of correction

The administrator will submit an incident report regarding outbreak. Also, shall provide in service training to staff regarding reporting requirements. Submit proof to CCL by POC date. Every covid positive must have Speical incident report within 24 hours.

Deadline recorded: Feb 4, 2022. A deadline is not proof that correction was completed.