TERRACES AT PARK MARINO, THE

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

87309 Storage Space: (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: Based on observation, the licensee did not comply with the section cited above in LPA observed cleaning solution on 7/9/24 in room #222 were a resident with dementia resides which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator removed cleaning solutions during the visit, and will discuss and write a plan with family regarding maintaining any hazardous materials in the room and provide a copy, and provide training to staff regarding observing and reporting chemical in rooms of residents with dementia to the department by by POC due date 6/7/24.

Deadline recorded: Jul 10, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87470(a)(1)(B)

Regulation authority

CCR

What the official deficiency says

(a) A licensee shall ensure that infection control practices are maintained as follows: (1) All staff and volunteers shall perform hand hygiene. (B) Hand hygiene shall be conducted as follows: 1. Immediately before and after resident care. 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 exited room #229 in which resident is in quarantine and did not use hand sanitizer or proper measure to prevent infection spread which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/07/2024 Plan of Correction Administrator will schedule training for all staff regarding infection control procedures and procedure to provide care to any residents in quarantine by POC due date 6/7/24, will notify the department by 6/7/24, and will provide the training by 6/13/24.

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 3 out of 7 residents bathrooms were tested and water temperature tested as follow; room #118 at 122.8 degrees F., room #122 at 121.0 degrees F., room #308 tested at 97.5 degrees F., which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/07/2024 Plan of Correction Administrator will adjust water heater and will ensure that the water temperature is within the required 105-120 degrees F., at all times. Facility has a proposal for repairs to ensure the water temperature remains within 105-120 degrees F. will follow with the proposal and will maintain a log for the three rooms for the next 7 days and will submit a copy of the log by 6/13/24.

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 1 out of 7 rooms, cleaning solution was observed in room #222 were a resident with dementia resides which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/07/2024 Plan of Correction Administrator will ensure that cleaning solutions are not stored in the room, and will discuss with family regarding maintaining any hazardous materials in the room, will certify in writing to the department by POC due date 6/7/24.

Official classification

Type B

Official code

87470(b)(2)

Regulation authority

CCR

What the official deficiency says

(b) In addition to subsection (a), when one or more residents in the facility are diagnosed with a contagious disease, the following shall apply: (2) All staff and volunteers providing direct care to a resident who has a contagious disease shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents or chemicals through the respiratory system, skin, or mucous membranes of the eyes, nose, or mouth. PPE may include gloves, gowns, masks, respirators, shoe coverings and eye protection. 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 was observed providing care to a resident with a contagious disease and staff was not wearing PPE supplies which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/13/2024 Plan of Correction Administrator will schedule training for all staff regarding infection control procedures and procedure to provide care to any residents, wearing PPE while providing care for residents in quarantine by POC due date 6/7/24, will notify the department by 6/7/24, and will provide the training by 6/13/24.

Official classification

Type B

Official code

87618(b)(3)(E)

Regulation authority

CCR

What the official deficiency says

(3) Ensuring that the use of oxygen equipment meets the following requirements: (E) Oxygen tanks that are not portable shall be secured in a stand or to the wall. 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 an oxygen tank was observed without a stand in room #118 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/13/2024 Plan of Correction Administrator will contact hospice and request a stand for the oxygen tank or will ensure if it is not needed it is removed from the room by POC due date 6/13/24.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2 ... Personal Rights of Residents...: (a)... facilities ... shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered... This requirement is not met as evidence by: Based on interviews and documents reviewed licensee did not ensure R1 whose physician report notes has dementia was provide dementia care at the facility which poses an immediate risk to the health, safety, or personal rights to the persons in care.

Official plan of correction

Administrator will meet with family and determine whether they can meet the needs of R1 and will provide care for dementia care, provide training for staff on steps in case a dementia resident is missing, and submit the plan and training schedule by POC due date 9/2/23.

Deadline recorded: Sep 2, 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

87705 Care of Persons with Dementia: (c) Licensees who accept and retain residents with dementia shall...: (5) ... have an annual medical assessment ... and a reappraisal done at least annually,... This requirement is not met as evidence by: Based on document review licensee failed to obtain an annual physician's report appraisal which poses a potential risk to the health, safety, or personal rights of the persons in care.

Official plan of correction

Administrator will obtain a physician's report and conduct a reappraisal and submit a copy to the department by POC due date 9/15/23.

Deadline recorded: Sep 15, 2023. 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 staff #3-#4 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/30/2023 Plan of Correction Administrator will provided additional topic to cover postural support, restricted health conditions and submit a copy to the department by POC due date 6/30/23.

Official classification

Type B

Official code

87458(b)(1)

Regulation authority

CCR

What the official deficiency says

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. 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 #5 does not have a TB 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: 06/30/2023 Plan of Correction Administrator will submit a copy of TB clearance for resident #5 to the department by POC due date 6/30/23.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. 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 memory care unit kitchen's sink was unlocked which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/30/2022 Plan of Correction Licensee will ensure to schedule in-service training regarding 87705 to staff by 6/30/22 and will submit a copy of in-service sign-in log to the department by 7/5/22.

Official classification

Type A

Official code

87506(c)(1)

Regulation authority

CCR

What the official deficiency says

87506 Residents Records: (c) All information and records obtained from or regarding residents shall be confidential. (1) The licensee shall be responsible for storing active...for safeguarding the confidentiality of their contents. ... This requirement is not met as evidence by: Based on interviews and document review licensee did not ensure staff were trained in safeguarding confidentially of resident #1 during a hospital transfer which poses a immediate health, safety, personal risk to persons in care.

Official plan of correction

Licensee will ensure that all staff is trained on 87506 and HIPPA law. Administrator will certify bysubmiting LIC 9098 by 3/10/22 and will ttrained staff and submit signing log and agenda to the department by 3/14/22.

Deadline recorded: Mar 10, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidence by: Based on interivews and documents reviewed licensee did not ensure under care and supervision resident #1's welfare was not endangered when assisting transfer to the hospital which is an immediate health, safety, personal risk to the persons in care.

Official plan of correction

Licensee will provide all staff training on Care and Supervision, Health and Safety Code 1569.2. Administrator will certify by submitting LIC 9098 by LIC 9098 and will submit a copy of signing log, and agenda to the department by 3/14/22.

Deadline recorded: Mar 10, 2022. A deadline is not proof that correction was completed.