CEDARS CARE HOME, THE

Official classification

Type A

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 interview with Administrator and record review the facility neglected to have at least one staff member who has CPR and 1st Aid training on duty at all times. Facility has 5 out of 5 caregivers that work at the facility without a valid CPR certificate which poses an immediate health, safety risk to residents in care.

Official plan of correction

POC Due Date: 12/19/2023 Plan of Correction Licensee to ensure that at least one staff on duty has CPR training at all times and all staff have current 1st Aid training. Licensee to submit LIC 9098 self certification that staff have been CPR trained per regulation and that facility will maintain a staff on duty who has CPR training at all times by POC due date 12/19/2023 & to provide copies of all 5 (S1-S5) certificates by 12/29/2023 to clear citation.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

87303(e)(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 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observation & interview with Administrator, the licensee did not comply with the section cited above in 3 out of 3 residents bathroom water faucets measured 130.8 degrees F & 135.5 degrees F, which are not within the allowable ranges of 105 to 120 degrees F. which poses/posed an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/19/2023 Plan of Correction Administrator lowered 1 of 2 hot water heaters during visit. Administrator to submit document stating they understand the regulation by 12/19/2023 with pic of proof of decreased water temp & Administrator will also submit as proof of correction a week measurement log of water temperature readings, taken once in the morning and once at night, showing temperatures in compliance with regulation 87303(e)(2), 2nd poc date Dec .25, 2023

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 LPA's observation & record review, the licensee did not comply with the section cited above in 5 out of 5 staff (S1-S5) did not have current/updated required trainings (any for 2023) which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/05/2024 Plan of Correction Licensee to ensure training requirements are met. Administrator agrees to submit proof of required trainings for S1-S5 to LPA by POC due date of 1/5/2024

Official classification

Type B

Official code

87463(c)

Regulation authority

CCR

What the official deficiency says

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's interview with Administrator and record review, the licensee did not comply with the section cited above in 3 out of 7 residents (R1, R2, & R3) did not have current updated reappraisals which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/05/2024 Plan of Correction Administrator to submit updated Reappraisals for R1, R2, & R3 by POC due date of 1/5/2024 to Clear citation with a statement of how this will be prevented going forward for residents.

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 and interviews conducted with Administrator, the facility did not comply with the section cited above per regulation, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/05/2024 Plan of Correction Licensee to submit written plan, outlining how facility will conduct required drills per regulation. Licensee will also conduct a drill and submit written evidence of completed drill to CCL by POC date of 01/05/2024.

Official classification

Type B

Official code

87705(c)(3)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance: This requirement is not met as evidenced by: Deficient Practice Statement Based on interview with Administrator & record review, the licensee did not comply with the section cited above in 5 out of 5 staff (S1-S5) did not have required training in their files which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/05/2024 Plan of Correction Administrator to ensure training requirements are met. Administrator agrees to submit proof of required trainings for S1-S5 to LPA by POC due date of 1/5/2024

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

87705(c)(5) Care of Persons with Dementia- Each resident with dementia shall have an annual medical assessment & reappraisal done at least annually... Ths requirement isnt met as evidenced by: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review & interview with Administrator, the licensee did not comply with the section cited above in 3 out of 7 residents (R1-R3) did not have current, updated medical assessments (602)'s which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/05/2024 Plan of Correction Licensee to ensure medical assessments are done, review and update to ensure all resident's needs are met. Licensee to submit a LIC 9098 self certification that facility has acquired LIC 602s medical assessment for residents R1, R2, R3, on file to be reviewed by the Department to CCL by POC date of 01/05/2024.

Official classification

Type B

Official code

87468.1(a)(2)

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: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the facility did not comply with the section cited above in 1 out of 8 bedrooms had storage in room and 2 out of 5 restrooms also had supplies, laundry, toilet seat in tub, walker in tub and other supplies (photos taken) which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/24/2021 Plan of Correction Facility will remove items from restrooms and shower and send LPA a photo when removed by 12/24/21.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review, the facility did not comply with the section cited above in 1 out of 1 alcohol bottles were accessible to residents in care. LPA observed alcohol in refrigerator by resident rooms. Alcohol was unlocked and accesible to residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/22/2021 Plan of Correction Facility agrees to keep all alcohol locked and inaccessible to residents in care. House Manager immediately removed alcohol and threw it away. Plan of correction corrected during visit.

Official classification

Type A

Official code

87468.1(a)(6)

Regulation authority

CCR

What the official deficiency says

87468.1 (a)(6) Personal Rights of Residents in All Facilities (a) Residents in all RCFEy shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This requirement was not met as evidenced by: Based on LPA observation, interview and record review R1’s movement was restricted at the facility. This poses an immediate risk to the health safety and personal rights of residents in care.

Official plan of correction

Licensee to ensure residents personal rights are maintained. Licensee agrees to review 87468.1 (a)(6) & provide a written plan that addresses how the facility will ensure the rights of resident to move freely at the facility by POC date 9/10/21. Licensee agrees to obtain training from an outside source for all staff on the topic of residents’ personal rights and to ensure that residents needs are being met by 9/10/21.

Deadline recorded: Sep 10, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1526.269

Regulation authority

HSC

What the official deficiency says

1569.269 Enumerated rights; severability (a)Residents of residential care facilities for the elderly shall have all of the following rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on LPA observation, interview and record review, R1’s telephone calls and visitations were restricted. This is an immediate risk to the health, safety and rights of the residents in care.

Official plan of correction

Licensee to ensure all residents are always treated with dignity & respect Licensee agrees to sign LIC 9098 attesting understanding of Health and Safety Code 15629 (a)(1) Enumerated Rights. Licensee agrees to submit a date for conducting training to all staff on regulation 1569.269(a)(1) by POC date & submit proof of training by POC due date of 9/10/21.

Deadline recorded: Sep 10, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211

Regulation authority

CCR

What the official deficiency says

87211(a)(1)(D) Reporting Requirements. (a) Each licensee shall furnish to the licensing agency...: (1) A written report shall be submitted to the licensing agency & person responsible for the resident within 7 days of the occurrence of ....(D) Any incident which threatens the welfare, safety or health of any resident....This requirement has not been met as evidenced by: Based on records review, interviews R1 had two incidents occurring on or around 7/4/2021 & incidents were not reported within regulatory timeframes and one incident that was not reported to CCL. R2 had an incident that was not reported within regulatory timeframes. This poses a potential risk to the health & safety of resident in care.

Official plan of correction

Licensee will ensure incidents are reported within regulatory timeframes. Licensee agrees to review the requirements of 87211 and to provide CCL with a signed and dated declaration attesting to the facility's compliance going forward by POC date of 9/24/21.

Deadline recorded: Sep 24, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.269

Regulation authority

HSC

What the official deficiency says

§1569.269 Enumerated rights; severability (a) Residents of RCFE shall have all of the following rights: (10) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement was not met as evidence by: This requirement was not met as evidence by: Based on the Department’s investigation R1 was the victim of elder abuse by staff which poses an immediate risk to the health, safety and Personal Rights of residents in care.

Official plan of correction

Licensee will ensure resident’s rights are maintained. Licensee agrees to provide LIC9098 notifying CCL that Elder Abuse prevention training from an outside vendor has been scheduled by POC due date of 9/10/21.

Deadline recorded: Sep 10, 2021. A deadline is not proof that correction was completed.