CIRCLE OF GRACE, INC.

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, the licensee did not comply with the section cited above in room #5's bedroom door is in disrepair; the bottom of the door and bottom door casing has damage caused by wheelchair; which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/10/2025 Plan of Correction Administrator agrees to submit picture proof evidence of the repairs.

Official classification

Type A

Official code

87465(h)(1)(C)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: (C) Because of potential dangers related to the medication itself, or due to physical arrangements in the facility and the condition or the habits of other persons in the facility, the medications are determined by either a physician, the administrator, or Department to be a safety hazard to others. 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 that at 9:37 AM morning medications were observed on R1's bedside table; resident refused to take the medications and did not want staff to take the medication pill away. Per Physician's Report, R1 cannot administer their own medications and there are 2 residents with Dementia diagnosis in the home. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/14/2025 Plan of Correction Administrator agrees to submit by tomorrow a written plan of correction and proof of staff training in regulation 87465.

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) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: Plan of Correction

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. 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 that resident (R1's) Irbesatan 300 mg & Alendronate Sodium 70 mg medications have not been refilled, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/01/2024 Plan of Correction Administrator contacted the pharmacy to request medication refills. 1. Submit picture proof that medications were received. 2. Submit proof of staff training

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 that the laundry room had unlocked cleaning supplies/disinfectants and detergents, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/01/2024 Plan of Correction Administrator shall submit proof the deficiency was corrected. Administrator stated that a lock will be placed in the laundry room cabinet.

Official classification

Type B

Official code

87618(b)(3)(B)

Regulation authority

CCR

What the official deficiency says

(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas. 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 that residents (R3 & R5) have oxygen tanks in their rooms, and a " No Smoking-Oxygen in Use " sign was not posted in appropriate area i.e., near the room door or at the facility entrance, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/07/2024 Plan of Correction Administrator shall ensure that a No Smoking-Oxygen In Use sign is posted when oxygen tanks are in the facility. Submit picture proof that the signs are posted.

Official classification

Type B

Official code

87307(a)(3)(C)

Regulation authority

CCR

What the official deficiency says

Personal Accommodations and Services Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillowcases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited. 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 that none of the resident beds had mattress pads, which poses a potential health and safety risk.

Official plan of correction

POC Due Date: 05/07/2024 Plan of Correction Submit picture proof and a written statement of how the deficiency was corrected.

Official classification

Type B

Official code

87468.1(a)(14)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To have reasonable access to telephones, to both make and receive confidential calls. The licensee may require reimbursement for long distance calls. This requirement was not met evidence by: Based on record review and interviews conducted, R1's conservator instructed staff to ban incoming phone calls from one of R1's adult children. However, conservatorship has not expressly taken the right away from R1; which poses a potential health and safety risk to persons in care.

Official plan of correction

Adminsitrator agreed to submit a plan of correction that includes: 1. Proof of meeting with R1's conservator 2. Staff training/log in regulation 87468.1

Deadline recorded: Aug 31, 2023. 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

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. 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 that R1 had a full length bed rail, and R2's bed had had two half rails converting it into a full rail. The residents are not enrolled in hospice; which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/31/2023 Plan of Correction Administrator agreed to remove the full bed rails from R1 & R2's bed, and obtain a physician order for half rails. Submit pictures of resident beds and copie of the physician orders by tomorrow.

Official classification

Type A

Official code

87705(l)(2)

Regulation authority

CCR

What the official deficiency says

(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates. 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 that the north side exterior gate door had a lock on the gate latch, whick poses an immediate health, safety or personal rights risk to persons in care. Picture was taken.

Official plan of correction

POC Due Date: 05/30/2023 Plan of Correction Locks shall be removed from all exterior exit doors. Staff removed lock during the visit. ***Cleared during the visit.