OAKMONT OF VALENCIA

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care: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...shall be permitted to assist... (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met, evidenced by, based on the SIR, (R1) was not giving medication according to doctor's orders. This is an immediate health and safety risk to residents in care.

Official plan of correction

POC cleared during visit. LPA obtained inservice training documents and sign-in sheets for staff all who attended in the training. LPA also requested a current and updated LIC500 to show the staffing schedules for the MC unit during the times medication is being administered to residents for all shifts.

Deadline recorded: Apr 10, 2026. A deadline is not proof that correction was completed.

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: (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 observation and medication record review, the licensee did not comply with the section cited above in [14] out of [101] medication record review, (6) records showed the initial dates of medication administration did not align with the actual medication counts, resulting in off-count errors, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/03/2025 Plan of Correction ED will send the updated medication checklist and training documents for recent medication training.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care: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...shall be permitted to assist... (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met, evidenced by, based on the SIR, (R1) was not giving inhaler according to doctor's orders. This is an immediate health and safety risk to residents in care.

Official plan of correction

POC cleared..Staff received medication training by credential agency, the Allen Flores group on April 8 and 9, 2025.

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

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care: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...shall be permitted to assist... (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met, evidenced by, based on the SIR, (R1) was not giving medication according to doctor's orders. This is an immediate health and safety risk to residents in care.

Official plan of correction

LPA received training documents from ED that was conducted by a licensed training agency who provided training to all medication technicians working at the facility. POC cleared during the visit.

Deadline recorded: Apr 18, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(d)(4)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements-General; (d) All personnel shall be given on the job training... This training and/or related experience shall provide knowledge of and skill in the following...Knowledge required to safely assist with prescribed medications which are self-administered... This requirement was not met as evidence by: based on a SIR submitted to Licensing, it was reported (8) residents missed their daily medication. This poses as an immediate health and safety risk to residents in care.

Official plan of correction

Executive Director (ED) Myla Belson will discuss with the Regional team in regards to training and safeguard implements for staff pertaining to administration of medication and other related training.

Deadline recorded: Mar 28, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care: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...shall be permitted to assist... following requirements are met:(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met, evidenced by, based on the SIR was submitted: (8) residents were not giving medication according to doctor's orders. This is an immediate health and safety risk to residents in care.

Official plan of correction

Executive Director (ED) Myla Belson will discuss with the Regional team in regards to training and safeguard implements for staff pertaining to administration of medication and other related training.

Deadline recorded: Mar 28, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(d)(4)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements-General; (d) All personnel shall be given on the job training... This training and/or related experience shall provide knowledge of and skill in the following...Knowledge required to safely assist with prescribed medications which are self-administered... This requirement was not met as evidence by: It was reported to Licensing staff #1 administered the wrong medication to resident #1. This poses as an immediate health and safety risk to residents in care.

Official plan of correction

An in-service re-training was conducted with medication technicians on 10/28/2024. LPA received by the training record. It was reported that the ED Myla Belson, Rickie McGregor (LVN) and Siliva Anaya (Regional Health Services Director) were present and attended the training. POC will be cleared, but further review will be required upon meeting with management pertaining to medication errors. A follow-up visit will take place at a later date and time.

Deadline recorded: Oct 30, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities: (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings... This requirement is not met as evidenced by: Based on LPA Ruiz inspection, during the initial visit, the licensee did not comply with the section cited above. Staff failed to clean R1’s shoes, saturated with diarrhea, which was found in the cabinet with R1’s toothbrush This poses/posed a potential health and safety risk to persons in care.

Official plan of correction

Administrator will have in-service training with all staff and submit copy of the proof to LPA by POC date.

Deadline recorded: Sep 4, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87625(b)(3)

Regulation authority

CCR

What the official deficiency says

Managed Incontinence: (b) In addition to Section 87611... the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry, and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by: Based on LPA Ruiz inspection/observation, during the initial visit, licensee did not comply with the section cited above by having a strong odor of feces/urine in room #122B and Memory Care Unit. This poses/posed a potential health and safety risk to persons in care.

Official plan of correction

Administrator will have in-service training regarding this section. Proof of training will be submitted to LPA by POC date.

Deadline recorded: Sep 4, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(a)(3)(C)

Regulation authority

CCR

What the official deficiency says

Personal Accommodations & Services: (a) Living accommodations and grounds shall be... Equipment and supplies necessary for personal care and maintenance of adequate hygiene... (C) Clean linen… shall be in good repair. This requirement is not met as evidenced by: Based on interview/observation conducted by LPA Ruiz, licensee did't comply with the section cited above by purchasing a laundry detergent that damaged residents personal items; clothing, bedsheets, which posed a potential health and safety risk to persons in care.

Official plan of correction

Administrator shall conduct an in-service training to housekeeping regarding residents' laundry. Submit copy of training, with staff's signatures, as proof of attendance, to LPA

Deadline recorded: Sep 4, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

Reporting requirements; (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1)A written report shall be submitted to the licensing agency...and to the person responsible for the resident within seven days ...and disposition of the case. This requirement was not met evidenced; based on documentation and interviews, facility submited one SIR for R1 when there were multiple falls. This is a potential health and safety risk to residents in care.

Official plan of correction

Executive Director (ED) will submit incident report for fall dated on 06/16/2024. During visit, LPA received SIR, and POC is cleared.

Deadline recorded: Jun 28, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

00000

Regulation authority

CCR

What the official deficiency says

Deficiency narrative not available.

Deadline recorded: Jun 15, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on records reviewed and interviews, it was determined that R2 choked or physically grabbed R1 by the neck. Additionally, there was a previous incident report that stated on 2/10/23, R2 was caught in R1's bedroom. The behavior issues exhibited by R2 towards R1 posess an immediate health and safety risk or personal rights risk to residents in care.

Official plan of correction

Executive Director stated that since the incident, R1 has been moved to another unit in memory care, in service training for managing difficult behaviors was completed for staff, and R2 had a physician’s appointment on 6/7/23 where their medications were adjusted, and an updated Individualized Service Plan (ISP) was completed today, on 6/15/2023. Deficiency cleared as of today's visit.

Deadline recorded: Jun 17, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(d)(4)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements-General; (d) All personnel shall be given on the job training... This training and/or related experience shall provide knowledge of and skill in the following...This requirement was not met as evidence by: (4) Knowledge required to safely assist with prescribed medications... Staff #1 administered the wrong medication to resident #1. This poses as an immediate health and safety risk to residents in care.

Official plan of correction

ED reported to LPA that a consulting group has been hired to provide additonal medication training to staff and the facility. ED will submit the subjects of the training and staff signatures of all who attended. LPA is aware during the visit, the consulting group is scheduled for 04/11 & 04/13, 2023. ED must submit documentation of training on 04/14/2023.

Deadline recorded: Apr 10, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. This requirement was not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above by not having a staff regularly check on or document any changes as agreed upon, which poses an immediate health and safety risk to residents in care.

Official plan of correction

The Licensee has agreed to do the following: 1. Develop and Submit facility protocol, which details how care staff are instructed to identify and document any changes in resident condition and what follow up actions will be taken and by whom Submit to CCL by POC date 2. Schedule an in-service training with care staff ensuring that staff are trained on the facility protocol as it pertains to the observation of the resident. Submit the sign-in sheet(s) to CCL by POC date

Deadline recorded: Mar 31, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(g)

Regulation authority

CCR

What the official deficiency says

87465(g) Incidental Medical and Dental Care. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health.... This requirement was not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above, as staff did not seek medical attention for R1 in a timely manner, which poses/posed an immediate health and safety risk to residents in care.

Official plan of correction

The Administrator has agreed to do the following: 1. Submit a Statement of Understanding, and the steps the facility will take to avoid similar issues from happening again and to ensure compliance to the cited regulation

Deadline recorded: Mar 31, 2023. 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

87463 Reappraisals: (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. This requirement was not met as evidence by: Based on review of documentation during investigation, the licensee did not comply with the section cited above by not completing a resident appraisal due to changes in R1’s medical condition that required the assistance with medications management, which poses/posed a potential health and safety risk to residents in care.

Official plan of correction

The Licensee agreed to develop a plan to address reappraisals of residents as frequently as necessary and provide in-service training to all staff regarding the Section 87463(a). Proof of training should be submitted to CCLD by POC date.

Deadline recorded: Mar 31, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(d)(4)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements-General (d) All personnel shall be given on the job training... This training and/or related experience shall provide knowledge of and skill in the following... (4) Knowledge required to safely assist with prescribed medications... This requirement was not met as evidence by: Based on the investigation, the licensee did not comply with the section cited above, for Staff #1 (S1), which poses/posed an immediate health and safety risk to residents in care.

Official plan of correction

Licensee agreed that all personnel (current and or future) will receive the required training. A verification of staff training will be submitted to CCLD by POC date.

Deadline recorded: Mar 31, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87405(b)

Regulation authority

CCR

What the official deficiency says

87405 Administrator - Qualifications and Duties (b) The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee. This requirement was not met as evidence by: Based on the investigation, the Administrator/Executive Director did not comply with the section cited above, failing to follow and carry out medication policy, which poses/posed an immediate health and safety risk to residents in care.

Official plan of correction

Licensee agreed that the facility Administrator/Executive Director, designee and all staff handling and/or administrering medications will be trained on the Facility's updated Medication Policy/Protocol. Proof of training will be submitted to CCLD by POC date.

Deadline recorded: Mar 31, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(4)

Regulation authority

CCR

What the official deficiency says

Care of Persons with Dementia (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement is not met as evidenced by: Basen on the information obtained, by the Investigator, Licensee/Administrator did not comply with the section cited above by knowing R1 needed 1:1 staffing and did not put into current appraisal as the appraisal was never updated, which poses an immediate health and safety risk to residents is care.

Official plan of correction

Licensee/Administrator will conduct by-weekly meetings with all staff regarding residents changes (if any). Licenee will also Submit Statement of Understanding, detailing how the facility will maintain compliance of Regulation 87705(4) by POC date to LPA

Deadline recorded: Mar 31, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(c)(5)(A)

Regulation authority

CCR

What the official deficiency says

Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia... (5) Each resident with dementia... A) When any medical assessment... ...corresponding changes shall be made... This requirement is not met as evidenced by: Based on the information obtained, by the Investigator, licensee did not comply with the section cited above by failing to provide an updated care plan to address R1's chronic falls, which poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee/Administrator will schedule vendorized training for all staff regarding Regulation 87705(c0(5)(A) Licensee/Administrator will submit the credentials of the trainer with the scheduled training dates by 03/31/2023 and completion of training by 03/31//2023.

Deadline recorded: Mar 31, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(c)(5)(A)

Regulation authority

CCR

What the official deficiency says

Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia... (5) Each resident with dementia... A) When any medical assessment... ...corresponding changes shall be made... This requirement is not met as evidenced by: Based on the information obtained, by the Investigator, licensee did not comply with the section cited above by failing to provide an updated care plan to address R1's chronic falls, which poses/posed an immediate health and safety risk to residents in care.

Official plan of correction

Licensee/Administrator agreed to schedule vendorized training for all staff regarding Regulation 87705(c0(5)(A) Licensee/Administrator will submit the credentials of the trainer with the scheduled training dates by 03/31/2023 and completion of training by 03/31/2023. Licenee/Administrator also agreed to Submit Statement of Understanding, detailing how the facility will maintain compliance of Regulation 87705(c)(5)A) by POC date to LPA Because this violation resulted in resident sustaining a serous bodily injury immediate civil penalty in the amount of $500 is issued.

Deadline recorded: Mar 31, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(4)

Regulation authority

CCR

What the official deficiency says

Care of Persons with Dementia (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement is not met as evidenced by: Based on the information obtained, by the Investigator, Licensee/Administrator did not comply with the section cited above by knowing that R1 needed 1:1 staffing and did not put into current appraisal as the appraisal was never updated, which poses/posed an immediate health and safety risk to residents is care.

Official plan of correction

Licensee/Administrator agreed to conduct by-weekly meetings with all staff regarding residents changes (if any). Licensee/Administrator will complete an appraisal of needs for specific client/residents to identify individual needs and develop a service plan for meeting those needs. If the client/resident is accepted for placement the staff person responsible for admission shall jointly develop a needs and services plan with the client/resident’s authorized representative referral agency/person, physician, social worker or other appropriate consultant. Licenee will also Submit Statement of Understanding, detailing how the facility will maintain compliance of Regulation 87705(4) by POC date to LPA

Deadline recorded: Mar 31, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

87211(a)(1) A,B & D Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)... This requirement is not met as evidenced by: Based on interviews and record reviews, conducted by LPA the licensee did not comply with the section cited above by failing to notify CCLD regarding the incident that occured on 11/06/22 which poses a potential health and safety risk to persons in care.

Official plan of correction

Licensee shall ensure a written report is submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence of any of the events. Copy of the training materials and certificates, for all staff members, shall be submitted to LPA by POC date.

Deadline recorded: Nov 17, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87101(b)(2)

Regulation authority

CCR

What the official deficiency says

Basic Services: (b)(2) " Basic Services, " as defined in Health and Safety Code section 1569.312, means those services required to be provided by the facility in order to obtain and maintain a license and in such combinations as may meet the needs... This requirement was not met as evidenced by: Based on information obtained during the course of the investigation licensee failed to protect R2 from being assaulted by R1 which poses an immediate health, safety and personal risk to persons in care.

Official plan of correction

Licensee/Administrator will schedule vendorized training for all staff regarding Regulation 87101... Licensee/Administrator will submit the credentials of the trainer with the scheduled training dates by 11/18/2022 and completion of training by 12/01/2022.

Deadline recorded: Nov 16, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87101(c)(3)(F)

Regulation authority

CCR

What the official deficiency says

Basic Services: (3) " Care and Supervision " means those activities which if provided shall require the facility… It involves assistance as needed with activities of daily living… (F) Supervision of resident schedules and activities; This requirement was not met as evidenced by: Based on information obtained during the course of the investigation S1 did not comply with the cited section by neglecting and leaving demetia residents unsupervised which led R1 to fall and sustain severe hip fracture that resulted in surgery.

Official plan of correction

Licensee/Administrator will schedule vendorized training for all staff regarding Regulation 87101... Licensee/Administrator will submit the credentials of the trainer with the scheduled training dates by 11/17/2022 and completion of training by 12/01/2022. Licenee/Administrator will also Submit Statement of Understanding, detailing how the facility will maintain compliance of Regulation 87101... Because this violation resulted in resident sustaining a serous bodily injury immediate civil penalty in the amount of $500 is issued.

Deadline recorded: Nov 17, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(6)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescriptions... This requirement is not met as evidenced by: Based on record reviews and interviews, licensee did not comply with the section above, as facility staff handling medications were not properly documenting prescribed and PRN medications on CSMDR, which poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee / Administrator will schedule vendorized training for all staff by 11/09/22 and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion by 11/09/22

Deadline recorded: Nov 8, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(h)(6)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescriptions... This requirement is not met as evidenced by: Based on record reviews and interviews, licensee did not comply with the section above, as facility staff handling medications were not properly documenting prescribed and PRN medications on CSMDR, which poses a potential health and safety rist to residents in care.

Official plan of correction

LPA was informed that the facility completed a medication training for all staff on 09/19/22. Documents obtained and POC cleared during today's visit

Deadline recorded: Oct 5, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on LPAs observation during the visit made on 07/27/22 the licensee did not comply with the section cited above. Resident’s pendant and/or emergency cord devices in both Memory Care Units were in poor repair and non-operational, which poses a potential health and safety risk to persons in care.

Official plan of correction

Licensee/Administrator placed an order for repairs on 07/22/22. During 09/01/22 visit LPA tested three emergency cord devices in rooms #135, #144 and #147 and observed all three emergency cord devices were in good condition during visit. POC cleared during visit.

Deadline recorded: Oct 5, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

87211(a)(1) A,B & D Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)... This requirement is not met as evidenced by: Based on interviews and record reviews, conducted by LPA during the visit made on 09/01/22, the licensee did not comply with the section cited above by failing to notify CCLD regarding the twelve incidents that occured between 08/03/22 -08/22/22, which poses a potential health and safety risk to persons in care.

Official plan of correction

Licensee shall ensure a written report is submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence of any of the events. Copy of the training materials and certificates, for all staff members, shall be submitted to LPA by POC date.

Deadline recorded: Sep 21, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(k)(6)

Regulation authority

CCR

What the official deficiency says

(k) The following initial and continuing requirements must be met for the licensee to utilize delayed egress devices on exterior doors... (6) Without violating Section 87468, Personal Rights, facility staff shall ensure the continued safety of residents... This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above by failing to ensure the safety of resident who wondered away from the facility, which poses an immediate health, safety and personal risk to persons in care.

Official plan of correction

Licensee shall provide written plan of action to show the steps they will take to prevent this issue from happening again. All staff trainig must be complete by POC date and copies of training materials along with sign-in sheet must be emailed to LPA

Deadline recorded: Sep 16, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

87211(a)(1) Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (D)... This requirement is not met as evidenced by: Based on interviews and record reviews, conducted by LPA during the visit made on 09/01/22, the licensee did not comply with the section cited above by failing to notify residents responsible party (in writing) about the incident within seven (7) days of the occurence, which poses a potential health and safety risk to persons in care.

Official plan of correction

Licensee shall ensure a written report is submitted to the person responsible for the resident within seven (7) days of the occurrence of any of the events. Licensee shall provide in-service training with all staff members andCopy of the training materials, along with the a sign-in sheet shall be submitted to LPA by POC date.

Deadline recorded: Sep 21, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87469(c)(3)

Regulation authority

CCR

What the official deficiency says

Specifically for a terminally ill resident that is receiving hospice services… For emergencies not directly related to the expected course of the resident’s terminal illness, the facility staff shall immediately telephone emergency response (9-1-1). This requirement was not met as evidenced by: Based on the information obtained during the course of the investigation the licensee/Administrator did not comply with the section cited by failing to call 911 when R1 was experiencing severe pain resulting from an unexplained injury which posed an immediate health and safety and personal rights risk to R1.

Official plan of correction

Licensee/Administrator will schedule vendorized training for all staff regarding Regulation 87469.. Licensee/administrator will submit the credentials of the trainer with the scheduled training dates by 8/12/2022 and completion of training by 9/2/2022. Licenee/Administrator will also Submit Statement of Understanding, detailing how the facility will maintain compliance of Regulation 87469.

Deadline recorded: Aug 12, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(d)

Regulation authority

CCR

What the official deficiency says

(d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457....... This requirement was not met as evidenced by: Based on information obtained during the course of the investigation the staff did not comply with the cited section by neglecting to put the footrests on R1’s wheelchair causing R1 to reportedly put foot down, fall forward and sustain severe facial injuries which posed an immediate health and safety and personal rights risk to R1.

Official plan of correction

Licensee/Administrator will schedule vendorized training for all staff regarding Regulation 87464.. Licensee/administrator will submit the credentials of the trainer with the scheduled training dates by 8/12/2022 and completion of training by 9/2/2022. Licenee/Administrator will also Submit Statement of Understanding, detailing how the facility will maintain compliance of Regulation 87464. Because this violation resulted in resident beingsustaining a serous bodily injury immediate civil penalty in the amount of $500 is issued.

Deadline recorded: Aug 12, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(h)(6)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescriptions... This requirement is not met as evidenced by: Based on record reviews and interviews, licensee did not comply with the section above, as facility staff handling medications were not properly documenting prescribed and PRN medications on CSMDR, which poses a potential health and safety rist to residents in care.

Official plan of correction

Administrator agreed to schedule vendorized training for all staff by 02/9/22 and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion by 02/09/22

Deadline recorded: Feb 9, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.69(a)(1)

Regulation authority

HSC

What the official deficiency says

§1569.69 Employees assisting residents with self-administration of medication; training requirements (1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 24 hours of initial training.... This requirement is not met as evidenced by: Based on record review and interviews, licensee failed to ensure staff were provided the required 24 hours of initial training, which poses a potential health and safety risk to residents in care.

Official plan of correction

Administrator agreed to schedule vendorized training for all staff by 02/3/22 and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion by 02/03/22.

Deadline recorded: Feb 9, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.33

Regulation authority

CCR

What the official deficiency says

Posting requirements 1569.33(h)(2) (2) Each residential care facility for the elderly shall post this poster in the main entryway of its facility. This requirement was not met as evidenced by Based on observations made by LPA on 1/11/22 at 11:09am, the licensee did not comply with the section cited above, in posting the Ombudsman’s poster in the main entryway, which posed a potential health, safety risk to persons in care.

Official plan of correction

Administrator agreed to remove the Ombudsman’s poster from the activity room (on a second floor) and post it in the main entryway (on a first floor).

Deadline recorded: Feb 9, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(k)(6)

Regulation authority

CCR

What the official deficiency says

(k) The following initial and continuing requirements must be met for the licensee to utilize delayed egress devices on exterior doors... (6) Without violating Section 87468, Personal Rights, facility staff shall ensure the continued safety of residents... This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above by failing to ensure the safety of resident who wondered away from the facility, which poses an immediate health, safety and personal risk to persons in care.

Official plan of correction

Licensee shall provide written plan of action to show the steps they will take to prevent this issue from happening again. POC must be submitted to CCL by POC due date.

Deadline recorded: Nov 5, 2021. A deadline is not proof that correction was completed.