CAREWELL MANOR

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, the licensee did not comply with the section cited above in LPA observing resident medications still in the bubble packs and signed off as given on the MAR with no explanation which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/24/2026 Plan of Correction Licensee stated they will conduct an in service training on medicaiton and send proof of in service to LPA by POC due date.

Official classification

Type B

Official code

87458(c)(1)(A)

Regulation authority

CCR

What the official deficiency says

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis. 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 2 of 5 residents not having a TB test on file which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/13/2026 Plan of Correction Licensee stated they will obtain TB tests for residents and send proof to LPA by POC due date.

Official classification

Type B

Official code

87705(f)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (f) Licensees that lock exterior doors or perimeter fence gates shall meet the following initial and continuing requirements: The Licensee did not comply with the section cited above due to the presence of a locked front door that requires a key to open from inside the facility. LPA determined the facility has not fulfilled the requirements to maintain a locked exterior door. The requirements are found in Title 22 Regulations 87705(f)(1)-(f)(4). This presents a potential personal rights and safety risk to residents in care.

Official plan of correction

The facility staff stated they will remove the lock from the exterior door by the assigned POC due date of 1/30/25.

Deadline recorded: Jan 30, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(d)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements-General (d)All personnel shall be given on the job training or have related experience in the job assigned to them. The Licensee did not comply with the section cited above due to the presence of a staff member who is providing food preparation and medication administration without prior experience or training to do so. This poses a potential health and safety risk to persons in care.

Official plan of correction

The Administrator stated they will ensure all staff complete their required training. Administrator will document training with the following: staff participating, topics covered and date/time of training. Facility staff will submit this documentation to the Department by the assigned POC due date.

Deadline recorded: Jan 30, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87207

Regulation authority

CCR

What the official deficiency says

87207 False Claims; No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. The Licensee did not comply with the section cited above due to the presence of a falsified CPR certification. This poses a potential health, safety or personal righs risk to persons in care.

Official plan of correction

The Administrator stated they will remove the falsified CPR document from all files. The Administrator stated they will ensure there are no falsified documents in any of the facility records.

Deadline recorded: Jan 30, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(c)(3)(D)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements-General(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training (3)(D) Policies and procedures regarding medications, including the knowledge in Section 87411(d)(4). The Licensee did not comply with the section cited above due to being unable to show proof that all staff who provide medication assistance have adequate medication administration training and/or experience. This poses a potential health and safety risk to persons in care.

Official plan of correction

The Administrator stated they will conduct an in-service training regarding medication administration and ensure all care staff attend. AD stated they will document the training with: staff in attendance, topics covered and date/time of training. AD stated they will submit proof of training to the Department by the assigned POC due date.

Deadline recorded: Jan 30, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above due to the presence of accessible bleach in two locations in the facility. This poses an immediate safety or risk to persons in care.

Official plan of correction

POC Due Date: 11/27/2024 Plan of Correction Administrator stated they will move all chemicals to a location inaccessible to residents by the assigned plan of corrections due date.

Official classification

Type A

Official code

87465(d)(3)

Regulation authority

CCR

What the official deficiency says

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to 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: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement is not met as evidenced by: Deficient Practice Statement Based on PRN medication review and PRN medication record review, the licensee did not comply with the section cited above due to the absence of a record of PRN doses administered to residents in care. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/27/2024 Plan of Correction Administrator stated they will conduct an in-service training regarding PRN Medication Administration and Documentation by the assigned due date. LPA advised AD to document the training with the following information: date/time the training was conducting, participating staff and topics covered. AD stated they will email LPA all documentation for this training by the assigned Plan of Correction due date of November 27.

Official classification

Type B

Official code

87208(c)

Regulation authority

CCR

What the official deficiency says

(c) A licensee who accepts or retains residents diagnosed by a physician to have dementia shall include additional information in the plan of operation as specified in Section 87705(b). 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 due to the absence of a dementia care plan. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/10/2024 Plan of Correction Administrator stated they will create and maintain in the facility a dementia care plan. Administrator stated they will email the completed plan to LPA by the assigned plan of corrections due date.

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 observations, the licensee did not comply with the section cited above due to the presence of nails on the backyard table, an inoperable shower, a missing igniter knob on the oven, an inoperable light in the refrigerator, a broken drawer in the kitchen and two bathroom sinks not draining. This poses a potential safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/10/2024 Plan of Correction Administrator stated they will remove the nails on the backyard table, replace the missing igniter knob on the oven, repair the shower, refrigerator light, kitchen drawer and bathroom sinks by the assigne plan of corrections due date.

Official classification

Type B

Official code

87303(f)(3)

Regulation authority

CCR

What the official deficiency says

(f) Solid waste shall be stored and disposed of as follows: (3) All containers, except movable bins, used for storage of solid wastes shall have tight-fitting covers on the containers; shall be in good repair; shall have external handles; and shall be leakproof and rodent-proof. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above due to the absence of lids on three trash cans. This poses a potential health risk to persons in care.

Official plan of correction

POC Due Date: 12/10/2024 Plan of Correction Administrator stated they will acquire tight-fitting lids for all trash can in the facility and place them on all trash cans by the assigned plan of corrections due date.

Official classification

Type B

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on medication and medication record review, the licensee did not comply with the section cited above due to the absence of a record of doses administered to residents in care. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/10/2024 Plan of Correction Administrator stated they will conduct an in-service training regarding Medication Administration and Documentation by the assigned due date. LPA advised AD to document the training with the following information: date/time the training was conducting, participating staff and topics covered. AD stated they will also maintain an updated MAR for medication and PRN as well as email LPA all documentation for this training by the assigned POC due date.

Official classification

Type B

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: Deficient Practice Statement Based on medication review, the licensee did not comply with the section cited above in due to multiple residents' medication being transferred between containers which poses a potential health or safety risk to persons in care.

Official plan of correction

POC Due Date: 12/10/2024 Plan of Correction Administrator stated they will conduct an in-service training regarding Medication Storage by the assigned due date. LPA advised AD to document the training with the following information: date/time the training was conducting, participating staff and topics covered. AD stated they ensure medication is stored in the originally receied containers and will email LPA all documentation for this training by the assigned Plan of Correction due date of December 10, 2024.

Official classification

Type B

Official code

87307(d)(2)

Regulation authority

CCR

What the official deficiency says

(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above due to the appearance of dirt and other indicators in the kitchen and bathroom in the shared room. This posesd a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/07/2024 Plan of Correction Facility staff cleaned the medicine cabinet in the shared room bathroom during the inspection. AD stated they will hire exterminators to come out to the facility and spray the bathroom, kitchen and any other areas where bugs have been seen. AD stated they will email LPA to notify them of the scheduled date of service. AD stated they will email LPA upon completion of the service.

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 due to the facility maintaining record of only one disaster drill in at least the last year. This poses a potential safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/17/2024 Plan of Correction Administrator stated they will schedule their next quarterly drill for July 2024 and email LPA to notify them of the scheduled drill by the assigned POC due date of 5/17/24.

Official classification

Type A

Official code

87606(c)

Regulation authority

CCR

What the official deficiency says

Per CCR 87606(c) on the Care of Bedridden Residents: " To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance(...). This requirement is not met as evidenced by: Based on interview conducted, facility observation and a review of records, resident R1 has been assessed to be bedridden while the facility is not in possession of an adequate fire clearance. This constitutes an immediate risk to the health and safety of residents in care.

Official plan of correction

Licensee will provide increased two-person supervision to the resident as well as provide the Department with a written statement of its intent to obtain a bedridden fire clearance from the competent fire authority or seek alternative placement for R1.

Deadline recorded: Apr 30, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(f)(1)(c)

Regulation authority

CCR

What the official deficiency says

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c)… (c) “…means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living…” which “includes assistance with taking medications, money management, or personal care.” This requirement was not met as evidenced by: Based on record review and interviews, one out of the two residents and two out of the three staff confirmed that care and supervision is not provided at all times which poses a potential Health, Safety, and Personal Rights risk to persons in care.

Official plan of correction

Administrator stated that they will submit the schedule for the nocturnal shift to LPA via email by POC due date.

Deadline recorded: Apr 3, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights of Residents in a Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs …” This requirement was not met as evidenced by: Based on observations and interviews, LPA and staff observed that diaper for one out of the six residents were soiled during the inspection which poses a potential Health, Safety, and Personal Rights risk to persons in care.

Official plan of correction

Administrator stated that they will create and submit a copy of the toileting log to LPA via email by POC due date.

Deadline recorded: Apr 3, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance " (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: (2) Request a transfer of a criminal record clearance... " This requirement was not met as evidenced by: Based on LPA's observations, interviews, and review of records, S1 was not associated at the time of the visit which poses an immediate Health, Safety, or Personal Rights risk to persons in care.

Official plan of correction

Administrator to provide proof of association for S1, and to submit an Acknowlegement of Understanding regarding the said deficiency to LPA via emaill by POC due date.

Deadline recorded: Feb 15, 2024. A deadline is not proof that correction was completed.