ST. SEBASTIAN'S HOME FOR THE ELDERLY

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures...(2) Faucets used by residents for personal care...shall deliver hot water. Hot water temperature controls shall be maintained ...not more than 120 degree F (49 degrees C).This requirement is not met as evidenced by: Based on observation, the hot water temperature was not maintained within the required range which poses an immediate health and safety concern for residents in care.

Official plan of correction

The licensee shall submit plan to ensure the hot water temperature is within the 105-120 degrees F and also a log in which the hot water was measured for each shift. These items shall be submitted to LPA by 8/8/24.

Deadline recorded: Aug 8, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

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 in that the hot water temperature readings were 126.7, 120.2, & 117.7 degrees Fahrenheit; which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/24/2024 Plan of Correction Submit a written plan of correction and a hot water temperature log that demonstrates the water was tested during each shift today and tomorrow.

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 in that Resident (R1's) medications were observed on top of the side dresser, and their roommate is ambulatory with Dementia, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/24/2024 Plan of Correction Submit proof of staff training and a written plan stating how the defiency was addressed.

Official classification

Type A

Official code

87608(a)(5)(A)

Regulation authority

CCR

What the official deficiency says

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above by having 1/2 rails on R1 & R2's beds without a physician's order, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/24/2024 Plan of Correction Submit a copy of the physician's order and/or proof that the request was sent to the physician.

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: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in that resident (R3) has full bed rails without being enrolled in hospice, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/24/2024 Plan of Correction Administrator agreed to remove the full rails from resident (R3's) bed because they are not enrolled in hospice. Submit a copy of the 1/2 bed rail physician order.

Official classification

Type B

Official code

87465(a)(8)(A)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care Services (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, the licensee did not comply with the section cited above by not having a first aid manual at the facillity,which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/30/2024 Plan of Correction Submit proof that a 1st Aid manual was purchased.

Official classification

Type B

Official code

87506(a)(b)(1)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records. (a)A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information. (b)Each resident’s record shall contain at least the following information: The requirement was not met as evidenced by record reviewed, LPA only observed LIC603 in resident's files which posted a potential risk of residents in care.

Official plan of correction

Administrator to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Licensee to submit a faxed or mailed copy of POC by due date.

Deadline recorded: Jul 14, 2023. 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 Reporting Requirements (a)(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 licensingThis report shall include the resident's nam.....e, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D)Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. The requirement was not met as evidenced by record review, LPA did not receive any incident reports from facility

Official plan of correction

Administrator to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Licensee to submit a faxed or mailed copy of POC by due date.

Deadline recorded: Jul 14, 2023. A deadline is not proof that correction was completed.