ST. JUDE'S ELDER CARE III

Official classification

Type B

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

(4) 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 record review, the licensee did not comply with the section cited above in that morning medications (Quetiapine Fumarate) was not dispensed for R1 on March 17, 2026 which posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/31/2026 Plan of Correction Licensee will conduct a staff training regarding assisting residents with self-administered medications and submit a training log listing topics covered and list of staff in attendence to LPA via email by POC due date.

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, overflow medication was stored with nonperishables and was accessible to residents, the licensee did not comply with the section cited above in 4 out of 4 residents, and/or visitors which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/25/2025 Plan of Correction *Staff removed overflow of medications and secured in centrally stored medicaions cabinet. No further action required.*

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(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 is not met as evidenced by: Deficient Practice Statement Based on observation, LPAs observed kitchen cabinets above microwave and stove to be sticky with residuethe licensee did not comply with the section cited above in 4 out of 4 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/02/2025 Plan of Correction Staff will clean and disinfect area above stove and outside cabinets doors. Picture proof must be submitted via email by 05/02/2025 to LPA Ramirez.

Official classification

Type B

Official code

87412(g)

Regulation authority

CCR

What the official deficiency says

(g) All personnel records shall be maintained at the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interviews, staff files were not maintained at the facility and were later dropped off, the licensee did not comply with the section cited above in 4 out of 4 residents, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/02/2025 Plan of Correction Licensee will draft a plan to address how the facility plans to comply with this regulation. Plan must be received by 05/2/2025 via email to LPA Ramirez.

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 evidence by: Based on observation licensee fail to ensure staff maintained cleaning solutions inaccessible to the residents in care at all times which poses an immediate risk to the health, safety, or personal rights of the persons in care.

Official plan of correction

Administrator moved the items during the visit and will conduct an in-service with the staff and submit a copy to the department by POC due date 4/2/25.

Deadline recorded: Apr 2, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

87608 Postural Supports: (a) ... Postural supports may be used... (5) Under no circumstances shall postural supports...(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care... This requirement is not met as evidence by: Based on observation licensee did not ensure to obtain a physician's bed rail request for full bed rails was in the resident's file who is not on hospice which poses a immediate risk to the health, safety, or personal rights of the persons in care.

Official plan of correction

Adminnistrator will request a half bed rail request for Resident #2 and will remove the other half bed rail and will submit the bed rail request and will send a picture of the bed rail to the department by POC due date 4/2/25. If nto able to obtain will remove the bed rails and submit a picture to the dept.

Deadline recorded: Apr 2, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

87608 Postural Supports : (a) ... Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record.... This requirement is not met as evidence by: Based on observation resident #1's bed was observed with half bed rails and a physician's order request was not observed on file which poses a potential risk to the health, safety, or personal rights of the person's in care.

Official plan of correction

Administrator will request a physician's half bed rail request for Resident #1 and submit a copy to the department by POC due date 4/9/25.

Deadline recorded: Apr 8, 2025. A deadline is not proof that correction was completed.

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. Water temperature was 120.9 -122.5 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/13/2023 Plan of Correction Staff adjusted water temperature during visit. ****NO FURTHER ACTION REQUIRED****

Official classification

Type B

Official code

87456(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review, the licensee did not comply with the section cited above One resident (R1) did not have pre-admission appraisal on file during visit. which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/17/2023 Plan of Correction Administrator will complete required pre appraisal for R1 and send proof to LPA by POC date.