MANOR CARE FACILITY

Official classification

Type B

Official code

87411(c)

Regulation authority

CCR

What the official deficiency says

87411(c) Personnel Requirements. All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625… This requirement was not met as evidenced by: Based on record review, the licensee did not comply with the section cited above when S1 did not have 4 hours of training in postural supports, restricted health conditions, hospice, and 6 hrs of hands on training which posed a potential health and safety risk to residents in care.

Official plan of correction

Administrator agrees to have S1 fully trained and submit proof to CCL by 08/14/2024.

Deadline recorded: Aug 14, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) 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 degrees C) and not more than 120 degree F (49 degrees C). 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 water temperature was below required range (96.1 and 96.4F) which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/27/2023 Plan of Correction The Administrator stated that she will adjust the water temperature to required range of 105-120-degree F and send proof to the LPA by due date.

Official classification

Type B

Official code

87305(a)

Regulation authority

CCR

What the official deficiency says

Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above in staff room located in the living area is not permitted which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/24/2023 Plan of Correction The Administrator stated that she will require a building permit for the staff room by due date.

Official classification

Type B

Official code

87412(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: 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 as no staff files were present during the time of the visit which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/10/2023 Plan of Correction The Administrator said that she will have personnel records for staff, including herself by due date.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. 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 as staff did not have the required training which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/10/2023 Plan of Correction The Administrator said that all staff will complete required annual training, including herself by due date.

Official classification

Type B

Official code

87467(a)(3)

Regulation authority

CCR

What the official deficiency says

(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals. 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 four (4) out of four (4) residents require updated appraisals/needs and service plan which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/10/2023 Plan of Correction The Administrator stated that she will complete residents appraisals/ needs and service plan by due date.

Official classification

Type B

Official code

1569.695(a)

Regulation authority

HSC

What the official deficiency says

(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: 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 as the disaster plan was not present during the time of the visit which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/10/2023 Plan of Correction The Administrator stated that she will create (and post) an emergency and disaster plan and send it to CCLD by due date.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and 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: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in one (1) out of four (4) residents with dementia diagnosis did not have updated physician’s report/ medical assessments which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/10/2023 Plan of Correction The Administrator stated that she will ensure that the annual medical assessment is completed for one (1) out of four (4) residents by due date.

Official classification

Type A

Official code

87468.1(a)(6)

Regulation authority

CCR

What the official deficiency says

87468.1 (a)(6) 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: (6)To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night...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 self-latching gate which exits to the front was padlocked, which poses an immediate health, safety or personal rights risk to persons in care..

Official plan of correction

POC Due Date: 10/27/2022 Plan of Correction The Licensee has agreed to do the following: 1. The padlocked needs to be removed within 24 hours. The Licensee with send a picture to the LPA.