NEWPORT MESA SENIOR LIVING

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

1569.625 Staff training; legislative findings; contents: (b)(2) .. training requirements shall also include .. 20 hours annually, eight hours ... shall be dementia care training.. and four hours .. shall be specific to postural supports, restricted health conditions, and hospice care... This requirement is not evidenced by: Based on records reviewed, the Licensee did not ensure that S3 received sufficent training for 2025 since S3 had 1 hour of training in dementia care & had 0 hours in postural supports, restricted health conditions, and hospice care. This poses a potential health and safety risk to persons in care.

Official plan of correction

The Executive Director stated that he will have S3 complete the required annual training for the year of 2025. The Executive Director agreed to provide LPA proof of completed training for S3 via email or fax by POC due date.

Deadline recorded: Jun 30, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care The licensee shall assist residents with self-administered medications as needed. The requirement is not met as evidenced by: Medications for all residents were administered late due to no qualified staff being available on the evening of December 7, 2025. In addition, medication audit for R2 indicates seven medications were not given as prescribed which poses an immediate health and safety risk to persons in care.

Official plan of correction

Memory Care Director stated daily and weekly medication audits have been put in place. All current med techs have received training from a license pharmacist. Memory Care Director to send proof to LPA by POC due date.

Deadline recorded: Jun 5, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(d)

Regulation authority

CCR

What the official deficiency says

87705(d) Care of Persons with Dementia The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement... The requirement was not met as evidenced by: R1 was able to exit the facility due to a malfunctioning door alarm which poses an immediate health and safety risk to persons in care.

Official plan of correction

ED stated new electronics for egress will be installed and functioning by POC due date. LPA will validate on a future visit.

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

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

...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: Based on LPA observation, hot water in the bathroom sink by room 8 measured at 126.5 degrees F which poses an immediate health and safety risk to persons in care.

Official plan of correction

Representative stated a third party will come and adjust water temperature for the facility. LPA to verify on a future visit.

Deadline recorded: Aug 6, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(i)

Regulation authority

CCR

What the official deficiency says

...All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall...Operate from each resident's living unit...Identify the specific resident living unit. This requirement is not met as evidenced by: Based on LPA observation, only one living unit had a signal system installed with poses a potential health and safety risk to persons in care.

Official plan of correction

Representative stated the signal system will be fully incorporated into each room by POC due date. LPA to verify on a future visit.

Deadline recorded: Aug 12, 2025. A deadline is not proof that correction was completed.

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 LPA observation, fruit flies are hovering in the prep kitchen, no recent fire service records are available, and smoke alarm is missing from room 19, which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 06/04/2025 Plan of Correction Facility to replace smoke alarm, service fire systems, and exterminate fruit flies by POC due date. LPA to return to verify.

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 LPA observation, hot water in the bathroom sink by room 8 measured at 89.9 degrees F which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 06/04/2025 Plan of Correction Facility to repair/fix faucet and notify LPA.

Official classification

Type B

Official code

87303(i)

Regulation authority

CCR

What the official deficiency says

(i) Facilities shall have signal systems which shall meet the following criteria: This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA obsevation and staff interview, there is no signal system at the facility which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 06/18/2025 Plan of Correction Facility to install signal system and advise LPA.

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 LPA records review, there was no emergency drill conducted within the last quarter which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 05/30/2025 Plan of Correction Facility to complete disaster drill by POC due date and email LPA proof.

Official classification

Type A

Official code

87705(b)(1)(8)

Regulation authority

CCR

What the official deficiency says

87705 Care of person with Dementia(b) Licensees shall be responsible for the following: (1) ensuring staff receive the following training as part of the training requirements specified in Section 87208 Plan of Operation: (B) Recognizing symptoms that may create or aggravate behavioral expression, as defined in Section 87101, Definitions, including, but not limited to, dehydration, UTI's, and problems with swallowing.This requirement was not met as evidenced by R1 was fed solid food and aspirated when physician’s report, appraisal and needs & service plan stated R1 was on a special pureed diet. This poses an immediate health, safety and or personal rights risk to persons in care.

Official plan of correction

Licensee to provide updated policy on Special diets & Activities of Daily living for residents and provide in service training with signatures of staff. Licensee to provide plan of correction by due date 3/13/2025.

Deadline recorded: Mar 13, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care. (a) … (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on documents and interviews, the licensee did not ensure 10 out of 10 residents received assistance with medications when the facility ran out of supply, which poses an immediate health risk to persons in care.

Official plan of correction

The licensee stated they will submit a plan to ensure residents medications are refilled timely to LPA by POC due date.

Deadline recorded: Mar 11, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(a)

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: This requirement is not met as evidenced by: Deficient Practice Statement Based on observations,interview, and records reviewed, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/23/2024 Plan of Correction The licensee has agreed to provide all staff members the annual required trainings and will provide LPA Allen proof of training and provide a written statement of understanding of cited regulations 87412 (a)- (h) signed by all staff members. Licensee has also agreed to update all staff files with the required First Aid/CPR certification, annual trainings, and health screenings.