TRUDEZ HOME CARE

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

Care of Persons with Dementia: The following shall be stored inaccessible to residents 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 by: Deficient Practice Statement Based on observation and interview the licensee did not comply with the section cited above by not ensuring medications for S2 are kept inaccessible to resident which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/22/2022 Plan of Correction Licensee/Administrator will need have an in-service training with all staff members regarding this deficiency and a proof of training shall be submitted to LPA bye POC date.

Official classification

Type A

Official code

87608(a)(5)(D)

Regulation authority

CCR

What the official deficiency says

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 observations mad, the licensee did not comply with the section cited above by utilizing full bedrails for R1 who is on hospice. However, licensee does not have hospice care plan which indicates the need for the rails which poses an immediate health, safety and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/22/2022 Plan of Correction Licensee/Administrator will request a current hospice care plan for a resident which indicates the need for the full rails. Copy of the Hospice care plans will need to be submitted by POC date.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

87506 (a) Resident Records. The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. 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 by not maintaining complete facility files for residents which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/28/2022 Plan of Correction Licensee/Administrator will complete files for all residents. Once completed licensee/administrator will submit a signed, dated self certification that all resident files have been, reviewed, updated and complete as required by the cited regulation.

Official classification

Type B

Official code

1569.652(c)

Regulation authority

HSC

What the official deficiency says

Termination of admission agreement upon death of resident; removal of resident’s... A refund of any fees paid in advance covering the time after the resident’s personal property has been removed... within 15 days after the personal property is removed. This requirement is not met as evidenced by: Based on record review & interview, licensee did not issue a refund within 15 days of R1's personal property being removed which posed a potential personal rights risk to residents in care.

Official plan of correction

Administrator will have to pay the pro-rated amount to R1's responsible party for the remaining days of September after R1 passed away and their belongings were removed. R1's rate for basic services was $2100/ month at the time of passing. Proof copy of check will be emailed to LPA by POC date

Deadline recorded: Dec 28, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87632(a)(1)

Regulation authority

CCR

What the official deficiency says

87632 Hospice Care Waiver (a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency... (1) Specification of the maximum number of terminally ill residents which the facility wants to have at any one time. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above. R1 was admitted on hospice as of 12/29/21. However, the facility did not have an approval for hospice, which poses an immediate health, safety risk to persons in care.

Official plan of correction

Administrator has agreed to submit a hospice waiver or relocate the resident immediately. Proof of waiver request or relocation address shall be submitted (CCLD) Community Care Licensing Department

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

Official classification

Type B

Official code

80061(b)(1)(D)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements. (b) during the operation of the facility...(1) below, a report shall be made to the licensing agency within...seven days following the occurrence of such event... (D) Any injury to any client.. This requirement was not met evidenced by: Based on the interviews and record review, the Administrator did not comply with the section cited above by not reporting an incident/death of two residents to Licensing agency, which poses a potential health and safety risk to clients in care.

Official plan of correction

Administrator ensured LPA that incident/death reports will be submitted acording to Licensing regulations. Death reports for both residents shall be submitted to LPA by POC date.

Deadline recorded: Feb 22, 2022. 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... This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above. The licensee failed to follow the infection control protocol on screening procedures. Staff was not familiar with screening procedures, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee agreed submit Mitigation Plan for an approval and train all staff on Mitigation Plan and infection control which includes screening. Staff sign-in sheet and training materials shall be e-mailed to LPA by POC date.

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

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement is not met as evidenced by Based on interviews, and record review, the licensee & administrator did not comply with the section cited above by allowing S1 to work at the facility prior to associating S1 to the facility which poses an immediate health and safety risk to residents in care.

Official plan of correction

Transfer of Criminal record clearance was completed on 11/9/2021. Deficiency cleared during visit.

Deadline recorded: Dec 22, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87615(a)(5)

Regulation authority

CCR

What the official deficiency says

(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (5)Residents who depend on others to perform all activities of daily living for them as set forth in Section This requirement is not met as evidenced by: Based on interview and observation the licensee/administrator did not comply with the cited section by admitting 1 (R2) and retaining 2 (R1 and R2) residents who depend on staff to perform all activities of Daily living for them which poses and immediate health and safety risk to residents in care.

Official plan of correction

Licensee/administrator will notify the department how this deficiency will be corrected.

Deadline recorded: Dec 23, 2021. 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: Based on observations the licensee did not comply with the section cited by utilizing full bed rails for 2 out of 5 residents (R1 and R4). Licensee does not have the hospice care plan to indicate the need for the full rails for R4 and R1 is currently not on hospice. which poses an immediate health, safety & personal rights risk to R1 and R4.

Official plan of correction

Licensee/Administrator will review the regulation., contact the hospice agency and obtained a current hospice care plan which will indicate the need for the full rail. Licensee will ensure to utilize full rail if order is obtained and not 2 half rails. Copy of the hospice care plans will be submitted as POC. Licensee/administrator will notify the Department in writing how they intend to clear the deficiency for R1. This deficiency is being recited because the licensee/administrator failed to submit the POC as discussed during the 6/7/2021 visit.

Deadline recorded: Dec 23, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

Postural Supports. A written order from a physician indicating the need for postural support shall be maintained in the resident’s record. The licensing agency is authorized to require additional documentation if needed. This requirement is not met as evidenced by: Based on Records review, observations the licensee did not comply with the section cited by not obtaining an order for postural support for R2 which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee/administrator will contact physicians and obtain orders for the postural support bed rail for R2 and submit copy as POC. This deficiency is being recited because the licensee/administrator failed to submit the POC as discussed during the 6/7/2021 visit.

Deadline recorded: Dec 23, 2021. 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

(c) Licensees who accept & retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment, & a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by: Based on LPA record review, the licensee did not comply with the section cited by not obtaining an complete Annual Medical assessment and not completing annual re-appraisals for 2 out of 5 residents diagnosed with dementia. This poses a potential health and safety risk to the residents in care.

Official plan of correction

Licensee/Administrator will obtain updated and complete medical assessments for R1 and R2 and complete re-appraisals. Copies of the documents will need to be submitted as POC. This deficiency is being recited because the licensee/administrator failed to submit the POC as discussed during the 6/7/2021 visit.

Deadline recorded: Dec 21, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(6)(D)

Regulation authority

CCR

What the official deficiency says

(D) Assistance with self-administration does not include forcing a resident to take medications, hiding or camouflaging medications in other substances without the resident's knowledge and consent, or otherwise infringing upon a resident's right to refuse to take a medication. This requirement is not met as evidenced by: Based on interview with staff, the licensee did not comply with the section cited above by crushing and camouflaging medications with food without a doctors order for 2 out of 5 residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee/administrator will contact R1 and R2's physicians and obtain an order to crush medications. Copy of the order will be submitted as POC. This deficiency is being recited because the licensee/administrator failed to submit the POC as discussed during the 6/7/2021 visit.

Deadline recorded: Dec 23, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(b)(c)(d)

Regulation authority

CCR

What the official deficiency says

Licensee is required to have PRN authorization letter on file signed by a physician to determine whether or not the residents can communicate the need and/or symptoms clearly for the as needed (PRN) medication. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above by not obtaining PRN authorization letters for 5 out of 5 residents which poses a immediate health, safety or personal rights risk to persons in care

Official plan of correction

Licensee/Administrator will contact residents Physicians to obtain PRN authorization letters for all residents who they provide medication assistance to. Copies of the PRN authorization letters will need to be submitted as POC. This deficiency is being recited because the licensee/administrator failed to submit the POC as discussed during the 6/7/2021 visit.

Deadline recorded: Dec 23, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(C3)(D3)

Regulation authority

CCR

What the official deficiency says

(3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above by not keeping PRN administration records when given to 3 out of 4 residents poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator will create PRN administration log to be utilized at the facility. A copy of the log with a written statement indicating that PRN logs will be used as necessary for all residents will be submitted as POC. This deficiency is being recited because the licensee/administrator failed to submit the POC as discussed during the 6/7/2021 visit.

Deadline recorded: Dec 23, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

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. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician & the resident's RP if any. This requirement is not met as evidenced by: Based on interview with staff the licensee did not comply with the section cited by not notifying prior residents physician of a change in condition

Official plan of correction

which posed an immediate health, safety or personal rights risk to persons in care. Licensee/administrator will notify the department what steps will be taken to ensure that they are in compliance with the cited regulation at all time. This deficiency is being recited because the licensee/administrator failed to submit the POC as discussed during the 6/7/2021 initial 10 day complaint visit.

Deadline recorded: Dec 23, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(5)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care Services. The licensee shall assist residents with self administered medications as needed/prescribed This requirement is not met as evidenced by Based on interview, record review and medication count, the licensee did not comply with the section cited by not assisting prior resident with self administration of medications as prescribed. which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee/Administrator and all staff will attend vendorized medication training. Training will need to be scheduled within 24 hours and completed within 14 days. Administrator will also contact a pharmacy and schedule a medication audit. Copy of the medication audit will need to be submitted as POC. This deficiency is being recited because the licensee/administrator failed to submit the POC as discussed during the 6/7/2021 initial 10 day complaint visit.

Deadline recorded: Dec 23, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(6)

Regulation authority

CCR

What the official deficiency says

(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: all the required information. This requirement is not met as evidenced by: based on record review the licensee/administrator did not comply with the section cited by not completing Centrally Stored Medication and Destruction record for 5 out of 5 residents which poses a potential health, safety and personal rights risk to persons in care.

Official plan of correction

Licensee/administrator will complete form for all residents after the medication audit. Copy of the completed forms along with a written statement that the forms will be completed and updated regularly will need to be submitted as POC. This deficiency is being recited because the licensee/administrator failed to submit the POC as discussed during the 6/7/2021 initial 10 day complaint visit.

Deadline recorded: Dec 23, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87615(a)(1)

Regulation authority

CCR

What the official deficiency says

Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3, 4, unstageable pressure injuries. This Requirement was not met as evidenced by: Based on information obtained during the investigation, the licensee/ administrator/staff did not comply with the cited section by retaining R1 at the facility who developed a prohibited health condition due to improper wound care which posed an immediate health and safety and personal rights risk to R1

Official plan of correction

Licensee/Administrator and all staff will attend at least 8 hours vendorized training regarding all sections cited on this report as well as allowable, restricted health conditions, hospice care, exception request. Verification of scheduled training with the trainers credentials will need to be submitted to LPA by 12/23/2021 and verification of completed training will need to be submitted to LPA by 1/7/2022 A civil penalty in the amount of $500 has been issued due the neglect/lack of timely medical care which resulted in R1 developing a prohibited health condition.

Deadline recorded: Jan 23, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87611(c)

Regulation authority

CCR

What the official deficiency says

87611 (c) In addition to section 87411(d), facility staff shall have knowledge and the ability to recognize and respond to problems and shall contact the physician, appropriately skilled professional, and/or vendor as necessary. This Requirement was not met as evidenced by: Based on information obtained during the investigation, the licensee/administrator/staff did not comply with the cited section by not having the knowledge and the ability to respond properly by contacting R1’s physician when R1 developed the pressure injury which posed an immediate health and safety and personal rights risk to R1

Official plan of correction

Licensee/Administrator and all staff will attend at least 8 hours vendorized training regarding all sections cited on this report as well as allowable, restricted health conditions, hospice care, exception request. Verification of scheduled training with the trainers credentials will need to be submitted to LPA by 12/23/2021 and verification of completed training will need to be submitted to LPA by 1/7/2022

Deadline recorded: Dec 23, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87631(a)(3)(A)

Regulation authority

CCR

What the official deficiency says

the licensee shall be permitted to accept or retain a resident who has a healing wound under the following circumstances:(3) Residents with a stage one or two pressure injury must have the condition diagnosed by a physician or an appropriately skilled professional. A)The resident shall receive care for the pressure injury from a physician or an appropriately skilled professional. This Requirement was not met as evidenced by: Based on information obtained during the investigation the licensee/administrator/staff did not comply with the cited section by not having R1’s pressure injury diagnosed and cared for by a physician or an appropriately skilled medical professional which posed an

Official plan of correction

immediate health and safety and personal rights risk to R1. Licensee/Administrator and all staff will attend at least 8 hours vendorized training regarding all sections cited on this report as well as allowable, restricted health conditions, hospice care, exception request. Verification of scheduled training with the trainers credentials will need to be submitted to LPA by 12/23/2021 and verification of completed training will need to be submitted to LPA by 1/7/2022

Deadline recorded: Dec 23, 2021. A deadline is not proof that correction was completed.