PASADENA MANSION

Official classification

Type B

Official code

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

Regulation authority

CCR

What the official deficiency says

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...(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 regulation has not been met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. The facility failed to report an incident reports regarding R1 fall, hospitalization and death to CCLD.

Official plan of correction

Administrator is to ensure that Title 22 Section 87211 regulations are met at all times. Administrator will submit incident reports and death report for Resident 1 (R1) fall, hospitalization and death to Community Care Licensing Division (CCLD) by 01/11/2024 5pm.

Deadline recorded: Jan 11, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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 bug killer spray and laundry detergent are accessible to the residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/01/2023 Plan of Correction Administrator will provide a lock or unaccessible area to store cleaning solutions and poisons and provide training to staff regarding section 87309 and safety concerns of accessibility of the above to dementia residents, and will submit a copy of training topic, sign in log, and duration of training to the department by POC due date 12/1/23.

Official classification

Type A

Official code

87309(b)

Regulation authority

CCR

What the official deficiency says

(b) Medicines shall be stored as specified in Section 87465(c) and separately from other items specified in (a) above. 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 staff's medication was observed on top of kitchen's dining table, an apothecary accessible to the residents was observed with varios medication which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/01/2023 Plan of Correction Administrator and staff removed the medications during the visit. Administrator will provided staff training on the importance of ensuring medication are kept unaccessible to the residents at all times and will submit to the department a copy of training topic, duration, and sign in log by POC due date 12/1/23.

Official classification

Type A

Official code

87465(a)(5)(D)

Regulation authority

CCR

What the official deficiency says

(5) Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. Assistance with self-administered medications shall be limited to the following: (D) Assistance with self-administration does not include forcing a resident to take medications, hiding or camouflaging medications in other substances without the resident's knowledge and consent, or otherwise infringing upon a resident's right to refuse to take a medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interviews, the licensee did not comply with the section cited above in R3's medication (pill) is put in the residents ensure for R3 to take without a physician's order which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/01/2023 Plan of Correction Administrator will obtain a physician's request to crush or mix medication for R3, will keep it on file, and submit a copy to the department, will provide medication training to staff by a medical professional/pharmacist and will submit a copy of training certificates by POC due date 12/1/23.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. 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 no record of emergency drills conducts was available for review which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/07/2023 Plan of Correction Administrator will conduct an emergency drill with residents and staff, create a log, and submit a copy to the department by POC due date 12/7/23.

Official classification

Type B

Official code

1569.695(d)

Regulation authority

HSC

What the official deficiency says

(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary. 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 Emergency Disaster plan has not been updated to the most current or does not meet the most current version of Emergency Disaster plan version (12/21) which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/07/2023 Plan of Correction Administrator will create an emergency disaster plan that meets the criteria of LIC 610(12/21) and will submit a copy to the department by POC due date 12/7/23.

Official classification

Type B

Official code

1569.695(f)(1)

Regulation authority

HSC

What the official deficiency says

(f) A facility shall have both of the following in place: (1) An evacuation chair at each stairwell, on or before July 1, 2019. 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 facility does not have an evacuation chair by the stairwell which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/07/2023 Plan of Correction Administrator will order and place evacuation chair at the end of the stairwell, will submit a picture and receipt to the department by POC due date 12/7/23.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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 cleaning,disinfecting supplies,and sharps were unlocked during the visit which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/22/2022 Plan of Correction Administrator will ensure staff maintain all cleaning supplies and sharps lock at all times, will certify in LIC 9098 by 9/22/22.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. 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 medication cabinet, and resident's medication observed in refrigerator were not lock during the visit which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/22/2022 Plan of Correction Administrator will ensure that medication is lock at all times, will certify and submit to the department by 9/22/22. Administrator is to submit picture of lock for refrigerator medication by 9/28/22.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by: Deficient Practice Statement Based on file review, the licensee did not comply with the section cited above in S2 does not have a TB test clearance on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/28/2022 Plan of Correction Administrator will submit TB test clearance to the department by POC due date 9/28/22.

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 during medication review, the licensee did not comply with the section cited above in 1 out of 3 residents, R1 medication was transfer from original bottle to another bottle which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/28/2022 Plan of Correction Administrator will provide training on medication proper storage section 87465 and submit agenda, and sign-in sheet by POC date 9/28/22.

Official classification

Type B

Official code

87465(e)

Regulation authority

CCR

What the official deficiency says

(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 resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and medication review, the licensee did not comply with the section cited above in R2 had PRN medication without prescription order, R3 did not have labels in PRN medication which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/28/2022 Plan of Correction Administrator will ensure all residents medication has the required labels and will submit pictures of the medication with labels to the department by POC due date 9/28/22.

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 file review, the licensee did not comply with the section cited above in R3 and R4 do not have a current annual physician's report which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/28/2022 Plan of Correction Administrator will obtain current physician's report and submit a copy to the department by POC 9/28/22.

Official classification

Type A

Official code

87204(b)

Regulation authority

CCR

What the official deficiency says

87204 Limitations - Capacity and Ambulatory Status (b) Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents. Residents whose condition becomes nomabulatory shall not remain in rooms restricted to ambulatory residents. 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 R4 status is nonambulatory and resides in second floor which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/22/2022 Plan of Correction Adminsitrator is to ensure R4 is place in a room per ambulatory status and will certify in LIC 9098 by POC due date 9/22/22.