CARMEL OAKS ASSISTED LIVING

Official classification

Type B

Official code

87465(d)

Regulation authority

CCR

What the official deficiency says

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to 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: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, observation and interview, the licensee did not comply with the section cited above. No record of the PRN Authorization letter on file for Resident #2 and Resident #3. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/09/2025 Plan of Correction Administrator agreed to obtain the PRN authorization letter for Resident #2 and Resident #3 from the physician and maintain on file. Submit copy of the PRN authorization letters obtained by due date 5/9/2025.

Official classification

Type B

Official code

87633(b)

Regulation authority

CCR

What the official deficiency says

(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above. Resident #6 was put on hospcie since 11/12/2024; no care plan observed on file. Administrator confirmed with the hospice agency during todays visit that the resident is no longer on hospice due to issues with the insurance. This poses/posed a potential health, safety risk to persons in care.

Official plan of correction

POC Due Date: 05/09/2025 Plan of Correction Administrator agreed to review hospice waiver and all requirements and submit a self-certified letter by 05/09/2025 acknowledging everything was reviewed and will ensure compliance with all hospice requirements in the future.

Official classification

Type B

Official code

87217(b)

Regulation authority

CCR

What the official deficiency says

8721(b)Safeguard for Personal Property & ValuablesEvery facility shall take appropriate measures to safeguard residents' ... personal property and valuables which have been entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all such articles...This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above when the licensee failed to safeguard and provide receipts for all personal property…, which resulted in R1’s clothing being lost, which posed a potential health and safety risk to residents in care.

Official plan of correction

POA: Administrator reimbursed the RP for the missing clothing. The POA has been cleared.

Deadline recorded: Jul 13, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

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, interview, and record review, the licensee did not comply with the section cited above in six out of six prescription medication bottles had incorrect number of pills, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/09/2023 Plan of Correction Licensee agrees to contract with a credentialed entity to conduct staff training on handling of the medication, medication bottles, and send a copy of the training materials, sign in sheet, and the name, address and phone number of the credential entity. Licensee will email proof of tratining to LPA .

Official classification

Type B

Official code

87465(a)(8)(A)

Regulation authority

CCR

What the official deficiency says

(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: (A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, and interview, the licensee did not comply with the section cited above as three first aid items were not available during the audit( first aid manual, scissors, twizzers, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/02/2023 Plan of Correction Licensee agrees to place missing items in the first aid kit by 06/02/2023, and send pictures to LPA via email.

Official classification

Type A

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

87555 (b)(8)-The following food service requirements shall apply: All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by: Based on observation of foods found in the pantry, the nutritional drinks had an expiration of 11/ 01/2022 and 12/01/2022, which poses an immediate health and safety danger to persons in care.

Official plan of correction

POC-Corrected today as Administrator agreed to throw away the expired food.

Deadline recorded: Jan 11, 2023. 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

87465(h)(2) The following requirements shall apply to medications which are centrally stored: 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: Based on observation, medications were found in unlocked cabinets and bedrooms and accessible to residents in care, which poses an immediate health and safety danger to persons in care.

Official plan of correction

POC: Administrator agreed to secure all medications.

Deadline recorded: Jan 11, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(i)

Regulation authority

CCR

What the official deficiency says

87565(i) Prescription medications which are not taken with the resident upon termination of services…shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. This requirement is not met as evidenced by: Based on observation, medications for a terminated resident were found in the facility, which poses a potential health and safety danger to persons in care.

Official plan of correction

POC: Administrator agreed to destroy the medications....

Deadline recorded: Jan 11, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87458(b)(1)

Regulation authority

CCR

What the official deficiency says

87458 (b)(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 diseases... This requirement is not met as evidenced by: Based on record review, the physician report on file for R1 was not completely filled out, which poses a potential health and safety danger to persons in care.

Official plan of correction

POC: The adminitartor has agreed to have a current physicians report completly filled out in residents file by 1/25/2023. Administrator will fax physician's report to LPA by 1/25/2023.

Deadline recorded: Jan 11, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87204

Regulation authority

CCR

What the official deficiency says

(a) A licensee shall not operate a facility beyond the condition and limitations specified on the license, incuding specifications of the maximum number of persons served who may recieve services at any one time. This requirement is not met as evidenced by: Based on observation and record review, the facility was serving seven residents, which is over the allowed capacity. This poses an immediate health and safety danger to persons in care.

Official plan of correction

ADministrator agrees to send in writing to the department that they are aware that they may not accept more than six residents at any given time in the facility.

Deadline recorded: Dec 9, 2022. 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 as knives were accessible in a kitchen drawer, which poses an immediate health and safety risk to residents in care.

Official plan of correction

POC Due Date: 04/29/2022 Plan of Correction The Administrator has agreed to do the following: 1. The knives were locked. Plan of Correction met.

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 and interview, the licensee did not comply with the section cited above, as one bottle (1), of personal medication was kept unlocked and accessible in Room #6, which poses an immediate health and safety risk to residents in care.

Official plan of correction

POC Due Date: 04/29/2022 Plan of Correction The Administrator has agreed to do the following: 1. The medication was removed to a secure location. Plan of Correction met.

Official classification

Type A

Official code

87412(a)(13)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation the licensee did not comply with the section cited above as one (1) out of six (6) staff didnot have a criminal record cleareance, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/06/2022 Plan of Correction The Administrator has agreed to the following: 1. The Administrator has agreed to do the following: Obtain verification from the Caregiver Background Check Bureau that S1 is cleared prior to working at the facility. 2. S1 will not work at the facility until the exemption is approved. by 5/6/2022.

Official classification

Type A

Official code

87412(a)(13)(A)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (A) A signed statement regarding their criminal record history as required by Section 87355(d). 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 as one(1) out of six (6) staff didnot have staff file and a signed statement regarding their criminal record history on file, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/06/2022 Plan of Correction 1. The Administrator has agreed to do the following: Obtain verification from the Caregiver Background Check Bureau that S1 is cleared prior to working at the facility. 2. S1 will not work at the facility until the exemption is approved. by 5/6/2022.

Official classification

Type B

Official code

87555(b)(26)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above, as the facility did not have a one-week supply of nonperishable food, which poses a potential health and safety risk to residents in care.

Official plan of correction

POC Due Date: 05/02/2022 Plan of Correction The Administrator has agreed to do the following: 1. Obtain additional food. Submit proof (ie. receipt, photos) to the Department by 5/02/2022.