COGIR OF BREA

Official classification

Type A

Official code

87303(i)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more...shall have a signal system which shall: (A) Operate from each resident's unit. (B) Transmit a visual and/or auditory (cont.) signal to a central staffed location or produce an auditory signal... loud enough to summon staff. (C) Identify the specific resident living unit. This requirement was not met as evidenced by: Resident call button was not in working order which poses an immediate health and safety risk to persons in care.

Official plan of correction

Executive Director and LPA toured Memory Care and tested the signal system. The signal system was in working order. The Plan of Correction wil be cleared by the visit today on August 21, 2025.

Deadline recorded: Aug 22, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (a) 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. (cont.) This requirement was not met as evidenced by: Resident outlets were not in working order. This poses an immediate health and safety risk to persons in care.

Official plan of correction

Executive Director and LPA toured Memory Care and tested outlets in resident room. Outlets were tested and in working order. The Plan of Correction will be cleared by the visit today on August 21, 2025.

Deadline recorded: Aug 22, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(5)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements (b) The following food service requirements shall apply: (5) Meals shall consist of an appropriate variety of foods and shall be planned with consideration for cultural and religious background and food habits of residents. Based on LPA observations, and interviews, this requirement is not met as evidence by: Three of four residents stated food was not always accessible, low quantity, per photos taken 10/15/24, and quality. This poses a potential health and safety risk for residents in care.

Official plan of correction

Facility will ensure there is adequate culinary line and server staff. Chef will submit menus to LPA by August 14, 2025 to provide documentation of food quality and minutes from the August Food Forum.

Deadline recorded: Aug 21, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(i)

Regulation authority

CCR

What the official deficiency says

87465(i) Incidental Medical and Dental Care: Prescription medications which are not taken with the resident upon termination of services... disposed of... .shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years. This requirement has not been met as evidenced by: LPAs observations show resident passed on 3/24/2025 and meds were not destroyed until 5/12/2025. A signed record was not found. This poses a potential health and safety risk to residents in care.

Official plan of correction

ED stated they will provide an in-service to all staff on medication storage and destruction and will send documentation of in-service to LPA by POC due date. Medications were disposed of on May 12, 2025.

Deadline recorded: Jul 3, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

Personnel Requirements - General 87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care...The licensing agency may require any facility to provide additional staff whenever it determines...that the needs of the particular residents, the extent of services provided... require such additional staff for the provision of adequate services.

Official plan of correction

This requirement is not met as evidenced by: Based on LPA observation and interviews of residents and staff on May 12-13, 2025, facility is understaffed to provide services necessary to meet resident needs. This poses an immediate health and safety risk to residents in care. Regional Vice President of Operations pulled care staff from another department to have adequate staffing on May 12, 2025. National Clinical Nurse, Regional Nurse and Health and Wellness Nurse from the sister community provided additional staff support on May 13, 2025.

Deadline recorded: May 14, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

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. This requirement was not met as evidenced by, The facility failed to report the falls of R! on April 3, 5, and 30 to the Agency, which poses a potential health and safety risks to residents in care.

Official plan of correction

Licensee agrees to train all staff on CCR 87211 and to submit proof of training to the LPA by the POC due date.

Deadline recorded: Apr 3, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

Basic services shall at a minimum include: (1) Care and supervision… This requirement was not met as evidenced by: Based on documents and interviews, the licensee did not ensure R1 received care and supervision, as a result R1 suffered multiple injuries because of falls suffered on April 25 , 2024 and April 29, 2024, which poses an immediate health and safety risk to persons in care. CIVIL PENALITY ASSESSED.

Official plan of correction

Licensee agrees to train care staff on CCR 87464 and to submit proof of training to LPA.

Deadline recorded: Mar 21, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.625(b)(1)(a)

Regulation authority

HSC

What the official deficiency says

(a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. 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 1 out of 5 staff members, staff 1 did not complete the required 20 hours of training within the first four weeks of employment which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/05/2024 Plan of Correction Licensee agrees to have staff 1 trained in compliance with the regulation above and to submit proof of training to the LPA by the POC due date.