NEWPORT BEACH MEMORY CARE

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 observation, the licensee did not comply with the section cited above as at least three separate taps tested during the present visit were found to be dispensing water above 120F which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/30/2025 Plan of Correction Licensee will adjust the weater heating system and ensure the dispensation of water below 120F throughout the facility. Licensing staff recommends recurring checks and the maintenance of a water temperature log also.

Official classification

Type B

Official code

87507(c)

Regulation authority

CCR

What the official deficiency says

(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. 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 as one admission agreement reviewed was found to be missing, two were missing both sets of signatures and another one was missing a signature from the responsible party. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/30/2025 Plan of Correction Licensee will ensure all admission agreements are adequately signed and provide signed documents to LPA before the plan of corrections due date.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (e) " All individuals subject to a criminal record review...(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department... " This requirement is not met as evidenced by: Based on observations and interviews, S1 was not fingerprint cleared prior to working or visiting the facility which poses an immediate Health, Safety, or Personal Rights risk to persons in care.

Official plan of correction

Wellness Director Karen Ashley will review regulation section 87355 Criminal Record Clearance and sign a statement of acknowledgement of understanding upon completion. Staff 1 has been removed from the schedule and will not return to work until the application process is completed and S1 is clear and associated to the facility. POC Due date is Tuesday, January 30, 2024.

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

Official classification

Type B

Official code

87705(c)(4)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. The requirement is not being met as evidenced by the presence of only two staff members working and the Wellness Director covering for a Med Tech who called off during a January 17, 2024 initial complaint visit.

Official plan of correction

Wellness Director Karen Ashley agrees to review regulation section 87705 Care of Persons with Dementia and send a signed statement or understanding once completed. Wellness Director Ashley will also send a plan of action that details what will be done to prevent a lack of staffing in the future. POC will be emailed to LPA Haley by Friday, February 2, 2024 at 1:00PM.

Deadline recorded: Feb 2, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87608(a)(2)

Regulation authority

CCR

What the official deficiency says

The California Code of Regulations Section 87608(a)(2) states that: " Postural supports shall be fastened or tied in a manner that permits quick release by the resident. " This requirement is not met as evidenced by: On multiple documented instances, residents were found to be unable to bring (...) (...) the legs of the recliner seat down, contributing to a fall incident. This constitutes a potential risk to the health, safety and personal rights of the individuals in care.

Official plan of correction

Licensee to provide in-service training to care staff regarding the safe use of the recliners with an emphasis making sure to not impeded a resident's personal right to ambulate and safely ensuring the residents' ability to exit the recliner if it is put up. Documentation of the training to be provided before POC due date

Deadline recorded: May 12, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

The California Code of Regulations Section 87405(a) Administrator - Qualifications and Duties states that: " (...) When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible. " This requirement was not met as evidenced by: Based on interviews conducted and records reviewed, when the former Administrator's resignation, no official designation of responsibility was made. This deficiency posed a potential risk to the health, safety and personal rights of individuals in care

Official plan of correction

A replacement administrator was hired and started employment on December 19, 2023. However, licensee will make sure that a qualified administrator is designated for coverage should another instance of prolonged absence occur.

Deadline recorded: Mar 6, 2023. 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

The California Code of Regulations Section 87303(a) on Maintenance and Operation states that: " The facility shall be (...) in good repair at all times. " This requirement was not met as evidenced by: Based on interviews conducted, an unspecified number of individual heating units were stated to have been non-functional, causing the previous administrator to provide heat by means of unauthorized floor heating units that were later removed before heating was repaired. This deficiency posed a potential risk to the health, safety and personal rights of individuals in care.

Official plan of correction

At the time the Substantiated findings were delivered, facility had already completed the required repairs and the entire facility was observed to be in compliance with mandated temperatures. The Plan of Corrections is considered to be cleared at this time.

Deadline recorded: Mar 6, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

The California Code of Regulations Section 87506(a) on Resident Records states that: " The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility (...) readily available to facility staff and to licensing agency staff. " This requirement is not met as evidenced by the missing file observed for resident R6. This deficiency poses a potential risk to the health, safety and personal rights of the individuals in care.

Official plan of correction

Licensee will ensure that a separate, complete and current record is being maintained at the facility for each individual in care at the facility before the Plan of Corrections due date.

Deadline recorded: Feb 3, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87507(f)

Regulation authority

CCR

What the official deficiency says

The California Code of Regulations Section 87507(f) regarding Admission Agreements indicates that : " The licensee shall comply with all applicable terms and conditions set forth in the admission agreement(...) " This requirement is not met as evidenced by: Based on observation, file review and interviews conducted, no refund has been issued in excess of the 15-day agreement upon admission. The licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee will provide documentation of the submission and effective payment of the refund to Licensing Program Analyst before the Plan of Corrections due date.

Deadline recorded: Nov 7, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87211(a)(2)

Regulation authority

CCR

What the official deficiency says

Each licensee shall furnish to the licensing agency such reports... including, but not limited to, the following: Occurrences, such as epidemic outbreaks.. which threaten the welfare, safety or health of residents.., shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. Based on interviews conducted, Licensee failed to ensure covid cases were reported to Licensing or Public Health. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee to forward a statement of understanding regarding reporting requirements and forward to LPA by POC due date.

Deadline recorded: Jul 29, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not being met as evidenced by: Based on observation, Licensee is not screening visitors to the facility. Facility was given an advisory on 04/12/2022 to begin screening visitors. This poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee agrees to screen all who enter the facility and forward proof to LPA by POC due date.

Deadline recorded: May 25, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.695(f)(1)

Regulation authority

HSC

What the official deficiency says

A facility shall have both of the following in place: (1) An evacuation chair at each stairwell, on or before July 1, 2019. 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 three out of three stairwells. All three stairwells do not have an evacuation chair which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 04/13/2022 Plan of Correction Please obtain evacuation chairs for all three stairwells and forward proof to LPA by POC due date.

Official classification

Type B

Official code

1569.695(a)(2)

Regulation authority

HSC

What the official deficiency says

Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure... including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. Facility does not have any emergency water on-site which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 04/26/2022 Plan of Correction Licensee to obtain emergency water and forward proof to LPA by POC due date.

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 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 two out of three physician reports. R1 and R3 do not have updated physician reports. This poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 04/26/2022 Plan of Correction Licensee to obtain updated physician reports and forward proof to LPA by POC due date.