MADONNA GARDENS

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 staff 1 does not have required annual dementia training, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/30/2026 Plan of Correction Administrator will submit proof staff files have been audited and a plan is in place to ensure all staff receives required annual training, and proof staff 1 has completed required tranining, and submit proof to LPA by POC date of 07/30/2026.

Official classification

Type B

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 LPA observed antacid medication in memory care resident room 1222, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/30/2026 Plan of Correction Administrator will train facili9ty staff on proper safe storage of medications and submit proof to LPA by POC date of 07/30/2026.

Official classification

Type A

Official code

87465(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care(4) The licensee shall assist residents with self-administered medications as needed.nThe following requirement has not been met as evidenced by: Facility residents did not get their PM medications on 03/22/2026, and 03/23/2026, which poses an immediate health, safety or personal rights risk to residents in care.

Official plan of correction

Facility staff involved in incident has been terminated, and facility medication techs will be provided with addittional med tech training and submit proof to LPA by POC date of 04/09/2026.

Deadline recorded: Apr 9, 2026. 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 in LPA observed water temperature in room 107 measured 123 degrees, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/07/2025 Plan of Correction Administrator will audit facility resident bathroom water temperatures and ensure temperatures including in room 107 are between 105 and 120, and send proof to LPA by POC date of 08/07/2025.

Official classification

Type B

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, record review the licensee did not comply with the section cited above in Resident 5's medication count is off by 2 doses, Resident 3 was given an extra dose of a medication on 07/16/2025, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/07/2025 Plan of Correction Administrator will provide training to facility medication technicians on medication administration and submit proof to LPA by POC date of 08/07/2025.

Official classification

Type B

Official code

87468.1(a)

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(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. The following requirements have not been met as evidenced by: Based on interviews conducted, and observation facility residents are being disrupted by doors closing loudly, and staff speaking loudly, which poses a potential, health, safety, or personal rights risk to residents in care.

Official plan of correction

Facility will make a plan to correct the loud sounds of doors, music, and doors throughout the facility hallways, and submit to LPA by POC date of 04/23/2025.

Deadline recorded: Apr 23, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)

Regulation authority

CCR

What the official deficiency says

87465Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: Resident 1's had ongoing symptoms of a skin condition. Resident 1's Physician recommended they be seen by a dermatologist several times

Official plan of correction

Administrator agrees to do In service training in the August health system to remind staff of appointments doctors are seeking for facility residents, and send proof to LPA by POC date of 09/27/2024.

Deadline recorded: Sep 27, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87633(b)

Regulation authority

CCR

What the official deficiency says

(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include 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 in Resident 1 does not have a current hospice plan of care on file, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/10/2024 Plan of Correction Administrator will provide hospice plan of care for Resident 1 by POC date of 07/10/2024.

Official classification

Type B

Official code

87211(a)

Regulation authority

CCR

What the official deficiency says

87211(a)Reporting Requirements. 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 of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, 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 following requirement has not been met as evidenced by: Facility staff did not report Resident 1's fall and transfer to hospital, which poses a potential, health, safety, or personal rights risk to residents in care.

Official plan of correction

Administrator will conduct staff training on Reporting Requirements, and send proof to LPA by POC date of 06/27/24

Deadline recorded: Jun 27, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(1)

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:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. The following requirement has not been met as evidenced by: Staff 1 exposed Resident 2's skin in a facility common area in front of other residents, and visitors. which poses

Official plan of correction

Administrator will conduct staff training on Personal rights of residents, and send proof to LPA by POC date of 06/27/2024.

Deadline recorded: Jun 27, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. The following requirement has not been met as evidenced by: Resident 1 was not provided prescribed medication for more than a month, which poses an immediate, health, safety, or personal rights risk to residents in care.

Official plan of correction

Administrator will conduct staff training on medication administration, and provide proof to LPA by POC date of 06/14/2024.

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

Official classification

Type A

Official code

Not listed

Regulation authority

CCR

What the official deficiency says

Deficiency narrative not available.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. The following requirement has not been met as evidenced by: Resident 1 was not given medication on 04/07/2024, and 4/08/2024, which poses an immediate, heatlh, safety, or personal rights risk to residents in care.

Official plan of correction

Administrator will conduct training with facility Staff 1 on medication administration, and submit proof to LPA by 04/11/2024 POC date.

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

Official classification

Type B

Official code

87211(a)(d)

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, 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 of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, 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 following requirement has not been met as evidenced by: The facility did not report Resident 1's missed medications to State Licensing, or Resident 1's Responsible party, which poses a potential, health, safety, or personal rights risk to residents in care.

Official plan of correction

Administrator will conduct training with staff on Reporting Requirements and submit proof to LPA by POC date of 04/24/2024.

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

Official classification

Type A

Official code

87468.1(a)

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:(1)To be accorded dignity in their personal relationships with staff, residents, and other persons. The following requirement has not been met as evidenced by: Resident 1 has been in several alteractions with other facility residents which poses an immediate, health, safety, or personal rights risk to residents in care.

Official plan of correction

Administrator will have Resident 1 re assesed immediately, and provide 1 on 1 care for Resident 1 to ensure the safety of other resients and submit proof to LPA Hurt by POC date of 10/12/2023.

Deadline recorded: Oct 12, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(8)

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:(8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. The following requirement has not been met as evidenced by: The facility did not document Responsible parties for several residents being notified after physical altercations Resident 1.

Official plan of correction

Administrator will conduct training with facility staff on Reporting to Resident Responsible Parties and submit proof to State Licesning by 10/11/2023 POC date.

Deadline recorded: Oct 25, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(c)(1)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (1) The facility has a nonambulatory fire clearance for each room that will be used to accommodate a resident with dementia who is unable to or unlikely to respond either physically or mentally to oral instructions relating to fire or other dangers and to independently take appropriate actions during emergencies or drills. The following requirement has not been met as evidenced by: LPA Hurt observed all Memory Care facility doors to be locked preventing emergency personnel services from easily entering rooms which poses an immediate health, safety, or personal rights risk to residents in care.

Official plan of correction

Administrator Tyler Barnes will unlock all memory care resident bedroom doors and send proof to LPA by POC date of 05/06/2023.

Deadline recorded: May 6, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87413(a)(2)

Regulation authority

CCR

What the official deficiency says

(a)In each facility: (2) Care and supervision of residents shall be provided without physical or verbal abuse, exploitation or prejudice. This requirement is not met as evidenced by: Based on interview and record review, staff did not provide care and supervision when R1 left the facility unsupervised on 04/26/22 at 10:40 a.m. and was located at 10:45 a.m. by facility neighbor which poses an immediate health and safety risks to persons in care.

Official plan of correction

LPA was informed staff have already been retrained on 05/03/22. LPA received copy of in-service training and rooster of attendance. POC cleared during visit.

Deadline recorded: May 9, 2022. 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 (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (4) Knowledge required to safely assist with prescribed medications which are self administered. This requirement was not met as evidenced by records reviewed Medtech 1 was not properly trained prior to administering medication. This is an immediate heath and safety risk to residents in care.

Official plan of correction

Licensee shall provide an in-service from an outside vendor for staff on medication administration. The facility will provide the department with documentation that the staff have completed the training and provide the department with an agenda of which topics were addressed. The information shall be submitted to the department by the POC date of 4/25/2022. If additional time is needed the facility will submit a request for an extension before the POC date.

Deadline recorded: Apr 25, 2022. 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 A plan for incidental medical and dental care shall be developed...The licensee shall assist residents with self administered medications as needed. This regulation was not met as evidence by: The licensee did not provide R1 with required refrigerated medication timely. Based on records reviewed, R1 was given four medication which were the wrong medication on 9/17/2021. This poses an immediate risk to residents in care.

Official plan of correction

The facility shall locate an outside Vendor to conduct training to all employees who administer medication to clients on Medication Management The plan shall be submitted by 4/25/2022 with the Vendor's name and dates of training. This information shall be submitted to CCL by due 4/25/2022

Deadline recorded: Apr 25, 2022. A deadline is not proof that correction was completed.