KENSINGTON SIERRA MADRE, THE

Official classification

Type A

Official code

87465(a)(5)(D)

Regulation authority

CCR

What the official deficiency says

(a) A plan for incidental medical shall be developed.The plan shall encourage medical care,provide for assistance in obtaining such care, compliance with the following: (5) staff may assist persons with self-administration. Assistance with self administered medications shall be limited to the following: (D) Assistance with self administration does not hiding,camouflaging medications in other substances without the resident's knowledge and consent, or infringing upon a resident's right to refuse to take a medication. This requirement was not met: Staff camouflaged R1's meds in their pudding without consent.

Official plan of correction

Licensee will certify plan to obtain consent for crushed and/or altered medication for R1 by 5/17/25. Licensee will obtain physician's order to specify the name of the medication to be crushed, specific dosage and obtain consent from R1's power of attorney for health, by 5/23/25.

Deadline recorded: May 17, 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

(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, the licensee did not comply with the section cited above as during tour LPA observed a medication cart a medication cart filled with prescribed medication belonging to various Residents, unlocked and unattended in hallway, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/14/2024 Plan of Correction ***Administrator/Director immediately had staff lock cart upon observation, all other medication carts throughout facility (also in hallways) were locked*** Administrator/Director to conduct training and council with all staff that assist with medication, and submit a copy of the training materials and training log with participants to LPA via email by 3/1/24.

Official classification

Type A

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

Maintenance and Operation. 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 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced; Between the hours of 10:45am - 12:30pm, the hot water temperature was tested throughout the facility and not measured within Title 22 Regulation guidelines. Men's room located on the first floor (near the bistro/parlor) was measured at 123.8 degrees F. Kitchen in Connection was measured at 123.9 degrees F. Activity room in Connection was measured at 121 degrees F. Kitchen located in room #238 was measured at 121 degrees F. Kitchen located in room #219 was measured at 122.5 degrees F. Bathroom located in room #219 was measured at 120.4 degrees F. Kitchen located in room #223 was measured at 120.5 degrees F. Kitchen in Haven was measured at 122.8 degrees F. Activity room in Haven was measured at 121.6 degrees F. This poses an immediate health, safety risk to persons in care.

Official plan of correction

***Citation was cleared at the time of visit and no further action is needed***

Deadline recorded: Mar 3, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

Care of Persons with Dementia. 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; At 11:26AM, Peroxide Multi Surface Cleaner /Disinfectant Spray and Vision Lens Cleaner were found in room #230, which is located in Connection. This poses an immediate health, safety risk to persons in care.

Official plan of correction

***Citation was cleared at the time of visit and no further action is needed***

Deadline recorded: Mar 3, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced; At 12:42pm, LPA discovered the following PRN medications were prescribed by Resident 1's (R1's) physician but were missing from the facility. ENEMA 19G-7G/ ML (Administer 1 Enema rectally every 48 hours as needed for constipation) & MI-ACID 400-400-40 MG (Take 2 tablespoonfuls 30ML by mouth every 4 hours as needed). This poses an immediate health, safety risk to persons in care.

Deadline recorded: Mar 4, 2022. A deadline is not proof that correction was completed.