EVERGREEN CARE HOME

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(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. 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 the stove burners only turning on by using a lighter which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/25/2025 Plan of Correction Licensee stated they will fix the stove so that it can turn on without using a lighter and send proof to LPA by POC due date.

Official classification

Type B

Official code

87412(a)(11)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. 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 of 2 staff not having a health screening which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/25/2025 Plan of Correction Licensee stated they will obtain a staff health screening and send to LPA by POC due date.

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 1 of 2 staff not having updated annual training for LPA to observe on file which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/25/2025 Plan of Correction Licensee stated they will train staff and send proof to LPA by POC due date.

Official classification

Type A

Official code

87465(c)(1)

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: (1) There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication, all of the information specified in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication of when the physician should be contacted for a medication reevaluation. 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 6 residents not having written direction from a physician for vitamins which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/05/2025 Plan of Correction Licensee stated they will discontinue use until physicians orders are obtained and send proof to LPA by POC due date.

Official classification

Type A

Official code

87309(a)(1)

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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above due to the knife drawer being unlocked. The AD also stated they did not know where the key was. This poses an immediate safety risk to persons in care.

Official plan of correction

POC Due Date: 11/07/2024 Plan of Correction Administrator stated they will get a new key made for the drawer. AD stated they will conduct an in-service training with facility staff. AD stated they will document the following: 1. Participating staff, 2. Date/Time, 3. Topic covered in training. AD stated they will email LPA the document regarding this training by Close of Business on the assigned POC due date.

Official classification

Type B

Official code

87412(a)(11)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. 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 out of 3 staff files reviewed which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/20/2024 Plan of Correction Administrator stated they will obtain completed health screenings for facility staff and send them to LPA via email by the assigned POC due date.

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 interview, the licensee did not comply with the section cited above due to not being able to present a disaster drill log.This poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 11/20/2024 Plan of Correction Administrator stated they will conduct a drill and document the folllowing: 1. Participating staff, 2. Date/Time of the drill 3. Type of drill conducted 4. Participating residents. AD stated they will send the record created to LPA via email by the assigned POC due date.

Official classification

Type B

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 6 resident beds.This poses a potential safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/20/2024 Plan of Correction Administrator stated they will remove the bed rails from the beds, take photos of both sides of both beds and send them LPA via email by the assigned POC due date.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

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 being met as evidenced by: Based on observation, LPA observed unsecured Aleve, acid controller, and Zenpep unsecured in a kitchen cabinet. This poses an immediate health and safety risk to residents in care. CIVIL PENALTY ASSESSED.

Official plan of correction

Licensee to secure noted items and forward proof to LPA by POC due date.

Deadline recorded: Dec 9, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468(c)(2)(A)

Regulation authority

CCR

What the official deficiency says

Licensees shall prominently post personal rights.. complaint information in areas accessible to residents, representatives, and the public... complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows:Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20 " x 26 " in size and be posted in the main entryway of the facility. This requirement is not being met as evidenced by: Based on observation, Licensee does not have the " Let Us No " poster posted in the facility. Licensee was advised on 11/04/2021 to post the poster. This poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee to post the poster in regulation size and forward proof to LPA by POC due date.

Deadline recorded: Dec 22, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This req is not being met as evidenced by: Based on record review, Licensee failed to ensure residents with Dementia have updated physician reports. Three out of four residents with Dementia do not have an updated physician report. This poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee to obtain updated physician reports and forward proof to LPA by POC due date.

Deadline recorded: Nov 22, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(a)(3)(A)

Regulation authority

CCR

What the official deficiency says

Equipment and supplies necessary for personal care and maintenance..: bed for each resident,... Each bed shall be equipped with good springs, a clean and comfortable mattress, available pillow(s) and lightweight warm bedding. This req is not being met as evidenced by: Based on observation, Licensee failed to ensure all residents have functional beds. Three out of five residents are sleeping on mattresses only. This poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee to submit an exception to allow residents to sleep on mattresses on the ground or obtain bed frame for residents by POC due date.

Deadline recorded: Nov 22, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

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. LPA observed unsecured medications in the unlocked garage refrigerator, and multiple cupboards and drawers in the kitchen. This poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 11/05/2021 Plan of Correction Licensee to secure all medications and forward proof to LPA by POC due date.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

The following shall be stored inacessible to residents with Dementia: 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, the licensee did not comply with the section cited above. LPA observed unsecured cleaning supplies in the unlocked garage, facility restroom, hall cupboard and under the sink. Additionally, LPA observed unsecured vitamins in an unlocked cabinet in the kitchen. This poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 11/05/2021 Plan of Correction Licensee to secure noted items and forward proof to LPA by POC due date.

Official classification

Type B

Official code

87608(a)(B)

Regulation authority

CCR

What the official deficiency says

Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. LPA observed Resident 2 has full bed rails and is not on hospice. This poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 11/11/2021 Plan of Correction Licensee to remove bed rails and forward proof to LPA by POC due date.