FULLERTON VILLA

Official classification

Type A

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care. 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 observation, interview and record reviews, the licensee did not comply with the section cited above in that medication is being pre-poured from original container more than 24 hours in advance (3 days) which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/23/2024 Plan of Correction Facility to immediately stop pre-pouring medication. Administrator has agreed to self certify understanding of regulation and provide proof of correction by 09/23/2024

Official classification

Type A

Official code

1569.2(c)

Regulation authority

HSC

What the official deficiency says

“Care and supervision” means the facility assumes responsibility for, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. This requirement is not met as evidence by: Based on information gathered, the facility did not assume responsibility for Resident’s wandering behavior, resulting in elopement from the facility, which poses an immediate safety risk to persons in care.

Official plan of correction

AAD stated resident has been placed on a 1:1 ratio to ensure 24-hour supervision and training regarding resident elopement would be conducted. AAD stated they would provide LPA with proof of training via email by POC.

Deadline recorded: Feb 13, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(2)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports... (2) Occurrences, such as epidemic outbreaks,...or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours... to the licensing agency and to the local health officer when appropriate. This requirement is not being met as evidenced by the outbreak of scabies in 2020. The outbreak was confirmed by staff and a resident. After reviewing incident reports submitted to the Regional Office it was discovered the scabies outbreak was not reported as required.

Official plan of correction

Administrator Lindley will review Regulation Section 87211 and email a statement of understanding and a plan of action that will prevent a failure to report in the future. Administrator Lindley will include who will be responsible for submitting incident reports and who will be the back up incase the designated personable is not available. The POC is due no later than Tuesday, December 19, 2023 at 1:00PM.

Deadline recorded: Dec 19, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(b)(1)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (b) In addition to the requirements as specified in…the plan of operation shall address the needs of residents with dementia, including: (1) Procedures for notifying the resident’s physician, family members and responsible persons who have requested notification, and conservator… when a resident’s behavior or condition changes. This requirement was not met as evidenced by: Based on LPA’s interviews and record review, two out of two staff made an admission that the authorized representative was notified 9 days after receiving the x-ray result which poses a potential Personal Rights risk to persons in care.

Official plan of correction

The administrator stated they will train their staff and provide proof of training addressing cited regulation to LPA via email by POC due date.

Deadline recorded: Oct 25, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87446

Regulation authority

CCR

What the official deficiency says

87446 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs…and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidenced by: Based on LPA's interviews and record review, two out of the two staff confirmed not seeking medical attention in a timely manner due to discovering the x-ray results 9 days later which poses an immediate Health, Safety, and Personal Rights risk to persons in care.

Official plan of correction

The administrator stated they will develop procedures to track medical orders and medical exam or test results and will train their staff. The proof of training addressing cited regulation will be provided to LPA via email by POC due date.

Deadline recorded: Oct 19, 2023. A deadline is not proof that correction was completed.