MADONNA GARDENS

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

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

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.