MORNINGSTAR OF PASADENA

Official classification

Type B

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. 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 1 out of 10 residents, R6 had a as needed prescribed medication out of original container which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/10/2025 Plan of Correction Administrator will request a refill for the medication and ensure all medications are maintained in their original container with prescription label will provide training to staff and will submit a copy of training and picture of medication to the department by POC due date 10/10/25.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. 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 10 residents did not have an appraisal done within the last 12 months which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/10/2025 Plan of Correction Administrator will conduct appraisals for R4,R5,R6, and R9 and submit a copy to the department by POC due date 10/10/25.

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 (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 requirement was not met as evidenced by: Based on observation, interviews conducted and file review, it was revealed that R1 was left unattended in the facility van from 3:00 pm to 8:45 pm, which poses an immediate health, safety, or personal rights risk to persons in care.

Official plan of correction

Executive Director will submit in writing what steps they will take to ensure that residents are not left unsupervised at any time. The Executive Director will also provide staff training regarding the process of a missing resident. The Plan of correction will need to be submitted to licensing by POC date. Executive Director requested Thursday 11/16/2023 to complete inservice training. **** Civil Penalties Assessed on LIC421M****

Deadline recorded: Nov 14, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(14)

Regulation authority

CCR

What the official deficiency says

87468.2(14) Additional Personal Rights of Residents in Privately Operated Facilities- To reasonable accommodation of their individual needs and preferences in all aspects of life in the facility, except when accommodation would endanger the health or safety of the individual resident or other residents. This requirement is not met as evidence by: Facility placed R1 in memory care unit eventhough R1 does not require memory care assistance or have a MCI diagnosis.

Official plan of correction

Licensee will certify by 8/5/23, plan to meet with R1's family and develop a plan on how R1's needs can be met while R1 is temporarily accommodated in room #212. Plan will include how the facility plans to protect R1 from memory care residents wandering into R1's room. Licensee will send minutes of meeting by 8/11/23 to LPA Ramirez via email.

Deadline recorded: Aug 5, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintanance 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 was not met as evidence by: R1 had flooding in room coming from kitchen sink which caused plumbing issues and flooding.

Official plan of correction

Licensee will provide LPA Ramirez will timeline of repairs by 8/11/23.

Deadline recorded: Aug 11, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(A)(D)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: 1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

Official plan of correction

Licensee will re-train staff on 87211 Reporting Requirements. Licensee will provide staff attendance list and training material that was used for training by 8/11/23. (A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidence by: Facility staff did not provide written reports within seven days of such occurences.

Deadline recorded: Aug 11, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(14)

Regulation authority

CCR

What the official deficiency says

87468.2(14) Additional Personal Rights of Residents in Privately Operated Facilities- To reasonable accommodation of their individual needs and preferences in all aspects of life in the facility, except when accommodation would endanger the health or safety of the individual resident or other residents. This requirement is not met as evidence by: Facility placed R1 in memory care unit eventhough R1 does not require memory care assistance or have a MCI diagnosis.

Official plan of correction

Licensee will certify by 8/5/23, plan to meet with R1's family and develop a plan on how R1's needs can be met while R1 is temporarily accommodated in room #212. Plan will include how the facility plans to protect R1 from memory care residents wandering into R1's room. Licensee will send minutes of meeting by 8/11/23 to LPA Ramirez via email.

Deadline recorded: Aug 5, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintanance 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.

Official plan of correction

Licensee will provide LPA Ramirez will timeline of repairs by 8/11/23.

Deadline recorded: Aug 11, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87211(a)(1)(2)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement was not met as evidence by: Licensee failed to notify this licensing agency that between 6-3-23 through 6-17-23, twenty-two (22) residents tested positive for COVID-19. From 6-4-23 through 6-17-23, four (4) facility staff tested positive for COVID-19. From 6-17-23 through 6-23-23, thirteen (13) additional residents tested positive for COVID-19. This licensing agency did not receive any written reports within seven (7) days of occurrence in reference to this recent epidemic outbreak, which began on 6-3-23.

Official plan of correction

Licensee will shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. Licensee will provide in house-training to staff on Reporting Requirements in regards to Title 22 regulations. Proof of training material and staff attendance is required to clear POC.

Deadline recorded: Jun 24, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87470(c)(1)(F)

Regulation authority

CCR

What the official deficiency says

87470 Infection Control Requirements (c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1) All staff and volunteers shall perform hand hygiene. Staff shall demonstrate knowledge of and skill in infection control, as appropriate to the job assigned and as evidenced by safe and effective job performance. This requirement is not met as evidence by: Licesee did not adhere to mitigation plan in regards to responding to outbreak of COVID-19.

Official plan of correction

Licensee will provide in house training to re-train staff on following facility mitigation plan. Proof of staff attendance is required to clear POC by due date.

Deadline recorded: Jun 24, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87415(3)

Regulation authority

CCR

What the official deficiency says

87415 (3) Night Supervision (3) In facilities caring for one hundred one (101) to two hundred (200) residents, one employee shall be on call, on the premises; one employee shall be on duty on the premises and awake; and one employee shall be on call and capable of responding within ten minutes. This requirement was not met as evidenced by: Emergency Fire personnel arrived at facility and could not access the facility because there was no one at the front desk to let them in and had to contact resident via phone to allow them entry. No staff was available at that time to allow the Fire Department Entry which poses a health and safety hazard for residents in care.

Official plan of correction

POC Administrator stated he will hire additional staff and train all staff to respond to emergency personnel during the overnight shift.

Deadline recorded: May 29, 2023. 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) The department may deny an application for a license or may suspend or revoke a license issued under this chapter upon any of the following grounds and in the manner provided in this chapter:(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: Upon arriving at the facility at 10:30 am LPA was greeted by Staff #1 (S1) and LPA was not screened for COVID upon entering the facility. This poses an immediate health and safety risk to persons in care.

Official plan of correction

Executive Director will ensure that all facility staff are following California Dept of Public Health and CCLD requirements by conducting an in-service training with the staff on the importance of COVID screening for all visitors, staff and residents. Executive Director will submit a copy of the sign-in sheet of all attendees along with the topics covered during the in-service training to CCL, by the POC due date.

Deadline recorded: Jan 20, 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) Each licensee shall furnish to the licensing agency such reports as the Department may require,...: (2) Occurrences, such as epidemic outbreaks,... or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported... to the licensing agency and to the local health officer when appropriate. Based on interviews, the Executive Director did not ensure that the Pasadena Public Health Department receives their weekly required lab reports for unvaccinated staff and residents which poses a potential health and safety risks to residents in care.

Official plan of correction

The Executive Director has delegated staff members to oversee the lab reports for unvaccinated individuals and ensure the lab reports are provided to PPHD weekly. Executive Director will submit a statement adhering to the reporting requirements by POC due date 12/17/21.

Deadline recorded: Dec 17, 2021. A deadline is not proof that correction was completed.