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

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 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.