LA POSADA

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. 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 on 2/26/26 LPAs observed the Memory Care Unit multi-purpose activity room refrigerator was unlocked and had tweezers in the freezer. In addition, the arts/crafts storage cabinet was unlocked and contained nail polish and nail polish remover, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/28/2026 Plan of Correction Submit a written plan of correction by tomorrow that addresses the tweezers and nail polish found in the Memory Care Unit. Submit by 3/6/2026 proof of staff in-service training.

Official classification

Type B

Official code

87412(g)

Regulation authority

CCR

What the official deficiency says

(g) All personnel records shall be maintained at the facility. 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 that staff (S7-S9's) files were not available for review, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/06/2026 Plan of Correction Submit self-certification that S7-S9's files have been found and all required file documents have been filed.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. 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 that staff (S2, S3 & S5) do not have proof of 1st Aid/CPR training in their files, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/06/2026 Plan of Correction Submit copies of S2, S3 and S5's 1st Aid/CPR training certificates.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. 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 that the facility did not provide proof that an emergency drill was conducted within the last quarter, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/06/2026 Plan of Correction Submit proof that an emergency drill has been completed.

Official classification

Type B

Official code

87307(a)(3)(C)

Regulation authority

CCR

What the official deficiency says

Personal Accommodations and Services (C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited. This requirement was not met evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in that rooms, 101, 104, 106, 107,110, 111, 112, 113, 202, 211, 311, 320 did not have a mattress pad, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/06/2026 Plan of Correction Submit a written plan of correction and picture proof that mattress pads have been placed on the beds in rooms , 101, 104, 106, 107,110, 111, 112, 113, 202, 211, 311, 320.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. 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 that staff (S4 & S6) do not have health screening/TB clearance on file, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/06/2026 Plan of Correction Submit copies of S4 & S6's health screening and TB exam clearance.

Official classification

Type B

Official code

87555(b)(7)

Regulation authority

CCR

What the official deficiency says

(7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review and kitchen observation, the licensee did not comply with the section cited above in that residents R4 & R8 have renal/kidney disease (dialysis) that require a renal diet, but they are not being served the modified diet, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/06/2026 Plan of Correction Administrator shall ensure all files of residents with special diet needs have a physician order on file and it is communicated with kitchen and med-tech staff. Submit a plan of correction indicating how the deficiency was addressed, and if needed obtain updated physician orders.

Official classification

Type B

Official code

87463(h)

Regulation authority

CCR

What the official deficiency says

(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. 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 that residents (R2, R7, R8, R9 & R10) medical assessments are more than 12 months old, ranging from 11/2022 - 1/2025, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/20/2026 Plan of Correction Submit updated copies of R2, R7, R8, R9 & R10 medical assessments.

Official classification

Type A

Official code

87465(b)

Regulation authority

CCR

What the official deficiency says

(b) If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication. 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 that residents (R1-R4) were missing physician ordered medications, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/27/2026 Plan of Correction Staff shall contact the resident's pharmacy and obtain refill medications for residents (R1-R4) by tomorrow.

Official classification

Type B

Official code

87211(a)(B)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements. Each licensee shall furnish to the licensing agency such reports..... A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below.... Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement was not met evidenced by:On 7/31/2024, resident (R1) sustained a right hand injury that resulted in an open flesh wound tear of approximately 4 inches, while the resident was transferred from the shower chair to the toilet. Facility faxed the incident report until 8/14/24, which posed a potential health and safety risk.

Official plan of correction

Executive Director shall ensure all Unusual Incident Reports are reported to CCL within 7 days of the occurrence of any reportable events. 1. Submit a written Plan of Correction 2. Proof of staff in-service training *Note: LPA obtained a file copy of the incident report.

Deadline recorded: Feb 21, 2025. 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 12 out 22 resident rooms and a kitchen sink hot water readings measured between 120 DF- 124.2 DF, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/16/2024 Plan of Correction Submit plan of correction by tomorrow and hot water temperature log of all resident rooms.

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 resident with self-administration, provided all of the following requirements are met: (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 record review, the licensee did not comply with the section cited above in that resident R1’s Medication Administration Record (MAR) dated Nov. 2024 listed 2 medication that were not filled. Acetaminophen 325 mg, 2 tabs every 4 hours PRN for fever over 100DF & Acetaminophen 325 mg 2 tabs every 6 hrs PRN for mild pain. This poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 11/16/2024 Plan of Correction Submit proof by tomorrow that R1's medications have been ordered via Omni Care, and picture proof of filled medications. In addition, proof of staff in-service training shall be submitted by Nov. 20, 2024.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. 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 that staff (S5 & S10) did not have health screenings or TB clearance on file, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/06/2024 Plan of Correction Administrator agreed to submit proof of S5 & S10's health screening/TB clearance.

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 in that 6 out 11 staff files do not have required annual training hours, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/06/2024 Plan of Correction Licensee shall ensure all staff are completing required training at the facility. Submit proof of completed staff training hours.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

PERSONNEL REQUIREMENTS - GENERAL 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 and 1569.69. (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. 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 that 9 out 11 staff files had expired 1st Aid/CPR training and/or no proof of training, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/06/2024 Plan of Correction Administrator shall ensure all staff maintain current 1st Aid/CPR training. Submit proof of training for all staff listed on LIC 811 to not have current training.

Official classification

Type B

Official code

87618(b)(3)(B)

Regulation authority

CCR

What the official deficiency says

Oxygen Administration - Gas and Liquid. (3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas. This requirement is not met as evidenced by: Based on observation, rooms 301, 314 & 326 have oxygen tanks in their rooms, and a " No Smoking-Oxygen in Use " sign was not posted outside resident room doors, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator shall ensure that a No Smoking-Oxygen In Use sign is posted on resident doors when oxygen tanks are used inside the room. Submit picture proof that the signs are posted and staff in-service training.

Deadline recorded: Sep 11, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(B)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements..(a) Each licensee shall furnish to the licensing agency such reports as the Department may require...(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in ..(B) Any serious injury as determined..and occurring while the resident is under facility supervision. This requirement is not met as evidenced by: Based on interview and records review, the Administrator failed to meet the reporting requirement and did not submit an Unusual Incident/Injury Report to CCL concerning R1's fall on 10/14/2022 which poses/posed a potential health, safety or personal rights risk to residents in care.

Official plan of correction

Administrator will ensure that the reporting requrements are met and to send a written/signed statement that Title 22 Regs. 87211 has been read, reviewed and understood to CCL/LPA by POC due date.

Deadline recorded: May 24, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87507(e)

Regulation authority

CCR

What the official deficiency says

Admission Agreements (e) The licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative, if any, immediately upon signing the admission agreement or modification. 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 that during file review of resident files it was observed that residents' admission agreement forms on file and being provided to residents and their responsible parties are not of the current licensee, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/04/2024 Plan of Correction Administrator agreed to issue residents an admission agreement approved by CCL during licensure with current licensee's name. Submit self-certification and a written statement that addresses how the deficiency was corrected.

Official classification

Type B

Official code

87307(a)(3)(C)

Regulation authority

CCR

What the official deficiency says

Personal Accommodations and Services. Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillowcases, mattress pads, bath towels, hand towels and wash cloths.... This requirement was not met by evidence of: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section above in that rooms 107, 110, 115, 218 did not have mattress pads, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/14/2023 Plan of Correction Administrator agreed to ensure that all resident beds have mattress pads. Submit proof of correction by POC due date.

Official classification

Type A

Official code

87355(e)(3)

Regulation authority

CCR

What the official deficiency says

(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: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or 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 that staff (S1) has worked at the facility since 2019, is cleared, but not associated to the facility; which poses an immediate health, safety or personal rights risk to persons in care. Civil penalty assessed.

Official plan of correction

POC Due Date: 12/08/2023 Plan of Correction Staff (S1) shall be associated to the facility by tomorrow. Submit Guardian proof.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. 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 there are discarded mattresses, chairs, and other furniture in the outdoor parking lot, the roof's rain gutter pipe had a missing pipe, the laundry room ceiling had exposed electrical wiring and an opened ceiling, and the parking lot floor had a steel beam sticking out of the ground,which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/14/2023 Plan of Correction Administrator agreed to submit picture proof evidence that the aforementioned items were discarded.

Official classification

Type B

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. 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 that staff (S2- S6) do not have 1st Aid/CPR certificates on file and/or have expired cards, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/14/2023 Plan of Correction Administrator shall submit proof of 1st Aid/CPR cards for staff (S2- S6) by POC due date.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. 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 that the last emergency drill was conducted on 7/6/2023, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/14/2023 Plan of Correction Administrator agreed to provide proof of emergency drill by POC due date.

Official classification

Type B

Official code

87633(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (2) The licensee remains in substantial compliance with the requirements of this section, with the provisions of the Residential Care Facilities for the Elderly Act (Health and Safety Code Section 1569 et seq.), all other requirements of Chapter 8 of Title 22 of the California Code of Regulations governing Residential Care Facilities for the Elderly, and with all terms and conditions of the waiver. 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 that there are 23 residents enrolled in hospice services, but the facility only has a hospice waiver for 20; which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/14/2023 Plan of Correction Administrator agreed to submit a hospice waiver increase by POC due date.

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 resident with self-administration, provided all of the following requirements are met: (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 during medication review, the licensee did not comply with the section cited above in that two (2) residents [R1 & R2} had unfilled PRN medications, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/06/2023 Plan of Correction Administrator shall ensure all missing PRN medications are filled by tomorrow. In addition, all staff that dispense medications shall receive in-service training. Submit in writting how this was corrected and attach proof of training by tomorrow.

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). 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 that the Memory Care Unit had an unlocked drawer with 2 pairs of scissors and sharp office supplies, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/06/2023 Plan of Correction Administrator shall submit a written plan of correction, proof of staff training, and a video/picture of the Memory Care unit cabinet showing that a lock was installed in the drawer.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

Care of Persons with Dementia. 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: Based on record review, the licensee did not comply with the section cited above in that annual assessments for two (2) Dementia residents R1 & R2 are older than 1 year; which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator shall ensure all Dementia residents have annual medical assesssments. 1. Submit proof that R1 & R2 have current annual assessments. 2. Submit proof of staff in-service training.

Deadline recorded: Jul 20, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(16)

Regulation authority

CCR

What the official deficiency says

87555 (b)(16) General Food Service Requirements (b) The following food service requirements shall apply: (16) In facilities licensed for sixteen (16) to forty-nine (49) residents, one person shall be designated who has primary responsibility for food planning, preparation and service. This person shall be provided with appropriate training. This requirement is not met as evidenced by: Staff (S1)/Dining Services Director's food handling certificate expired on 3/25/2022. Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in S1/Dining Services Director does not have a current Food Handling Training Certificate which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/13/2022 Plan of Correction Facility Administrator to submit proof of staff (S1) of a current Food Handling Training Certificate by POC due date.

Official classification

Type B

Official code

87307(a)(3)(C)

Regulation authority

CCR

What the official deficiency says

Personal Accommodations and Services. Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths.... This requirement was not met by evidence of: This requirement is not met as evidenced by: Rooms 102, 104, 108, 110, 212, 214, 216, 220, 309, 311 did not have mattress pads. Deficient Practice Statement Based on physical plant observations, the majority of rooms in the Memory Care unit had no mattress pads; rooms 102, 104, 108, 110, 212, 214, 216, 220, 309, 311 did not have mattress pads in the beds. This poses a potential health and safety risk.

Official plan of correction

POC Due Date: 12/13/2022 Plan of Correction Administrator agreed to ensure that all resident beds have mattress pads. Submit proof of correction.

Official classification

Type A

Official code

87705(j)

Regulation authority

CCR

What the official deficiency says

Care of Persons with Dementia. The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. 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 all the Memory Care unit rooms had window auditory alarms that do not have sound to alert staff. The alarm system registers in the front desk area that does not always have staff; which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/16/2022 Plan of Correction Administrator shall ensure that all auditory devices on the exit doors and windows are turned on, and operable at all times. Administrator agreed to submit a written plan of correction and proof of staff training by tomorrow.

Official classification

Type B

Official code

87303(c)

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation (c) All window screens shall be clean and maintained in good repair. 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 windows by the 2nd floor game room did not have window screens; which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/13/2022 Plan of Correction Administrator shall submit picture proof that window screens were installed in the game room window.

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 ........ Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Residents (R1- R4) were missing medications ordered by their MD. Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in that residents (R1-R4) were missing medications; which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/17/2022 Plan of Correction Administrator shall submit a written plan stating how this deficiency will be correct. Facility shall contact pharmacy and place prescription order. A RN or Pharmacist shall conduct staff in-service training regarding medication administration. Provide proof of in-service.