ASSISTED SENIOR CARE FACILITY

Official classification

Type A

Official code

87611(a)

Regulation authority

CCR

What the official deficiency says

87611(a) General Requirements for Allowable Health Conditions (a) Prior to accepting or retaining a resident with an allowable health condition as specified in Section 87618… Section 87631, Healing Wounds; licensees… shall obtain Department approval: This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above by not obtaining an approval from the department for R1's prohibited health condiction (stage 3 pressure wound) which was discovered on 04/28/25 this poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

The Aministrator will submit a written request for an exception for R1's restricted health condition (Pressure Wound Care) by POC due date.

Deadline recorded: May 5, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87615(a)

Regulation authority

CCR

What the official deficiency says

87615(a) Prohibited Health Conditions (a)Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. Based on record review & interviews the licensee did not comply with the section cited by R1 developing stage 3 ulcers while under the facility care. This poses an immediate health and safety risk to the resident in care.

Official plan of correction

The Administrator has agreed to the following: All staff take state approved training on the regulation Prohibited Health Conditions. Submit training schedule with the vendors name, date of schedule. Upon completion submit the training material and staff sign in sheet.

Deadline recorded: May 5, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

Basic Service: (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 evidenced by: Based on interviews and record reviews the licensee failed to provide care and supervision to R1 who developed stage 3 ulcers residing at the facility which poses a potential health and safety risk to residents in care.

Official plan of correction

Administrators will schedule 2 hours vendorized training for themselves and all staff related to the cited section. 1) Verification of the scheduled training with the credentials of the trainer will need to be emailed to the LPA by POC due date.

Deadline recorded: May 9, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(c)(2)(A-D)

Regulation authority

CCR

What the official deficiency says

Personnel Records: (c) Licensees shall maintain in the personnel records verification of required staff training and orientation. (2) Documentation of staff training shall include: This requirement is not met as evidenced by: Based on interviews and record review the licensee did not comply by not making sure all trained staff followed the " in service " training knowledge and conducted daily body checks on R1 for the history of skin breakdown which poses a potential health and safety risk to residents in care.

Official plan of correction

The Administrator shall submit proof that all staff will complete " in service " trainings. The Administrator shall submit proof to LPA by POC due date. Additionally, submit a complete body check forms for each resident for the next two week.

Deadline recorded: May 9, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

Reappraisals: (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary....... the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical... This requirement is not met as evidenced by: Based on interview and record reviews, licensee did not comply with the section cited above. Administrator completed partial reappraisals for R1 on 04/30/2025 upon observing the stage 3 ulcer on R1's buttocks area, which poses/posed a potential health and safety risk to resident in care.

Official plan of correction

Administrator agreed to submit a statement of understanding on how all residents will have a proper reappraisal when changes occur to ensure their needs are met. Additionally, the Administrator will properly complete the reappraisal for R1 and submit to LPA by POC date.

Deadline recorded: May 9, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

7465 Incidental Medical and Dental Care(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... This requirement is not met as evidenced by: Deficient Practice Statement Based on observations the caregiver medications were unlocked in a resident closet as well as other medications accessible in all of the residents bedrooms' closets. The Administrator did not ensure that the centrally stored medications were locked and inaccessible to resident in care. This poses an immediate health and safety hazard to residents in care.

Official plan of correction

POC Due Date: 10/30/2024 Plan of Correction During the visit the administrator designee Rima Agaronyan immediately removed the caregiver medications and as well locked all the other residents medications. The administrator will do an in service with staff to ensure medication are secured, and they are locked after each use and each time after opening the medication drawer. Documentation will be submitted as proof of correction with staff names and date and training material used.