TWIN HEARTS SENIOR CARE II

Official classification

Type A

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 that the backdoor to Bedroom #1 was shattered which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 12/08/2025 Plan of Correction Licensee removed the shattered glass from the first pane of the backdoor during LPA's visit. Licensee agrees to provide proof of that the glass repair to the Department by 1/5/2025.

Official classification

Type B

Official code

87463(h)

Regulation authority

CCR

What the official deficiency says

(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above in that Resident #1 (R1) had not received nor refused an annual route visit once every twelve months which posed a potential health, safety or personal rights risk to one (1) out of four (4) residents in care.

Official plan of correction

POC Due Date: 01/05/2026 Plan of Correction Licensee agrees to provide proof of documentation of R1's annual routine visit or refusal, if applicable, to the Department by POC date of 1/5/2026.

Official classification

Type B

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above in that Staff #1 (S1) did not have cardiopulmonary resuscitation (CPR) training and first aid training and was the only staff member on the premises when LPA arrived which posed a potential health and safety risk to four (4) out of four (4) residents in care.

Official plan of correction

POC Due Date: 01/05/2026 Plan of Correction Licensee agrees to provide proof of S1's CPR and first aid training to the Department by POC date of 1/5/2026.

Official classification

Type A

Official code

87355(e)(3)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or 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 by S1 and S2 criminal record clearance not transfer which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/27/2025 Plan of Correction Licensee stated they will submit proof of clearance transfer request to LPA Rico.

Official classification

Type A

Official code

87465(d)(3)

Regulation authority

CCR

What the official deficiency says

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to 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: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. 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 but not having (6) out of the (6) residents PRN medication resposne documented which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/27/2025 Plan of Correction Licensee stated they will train their staff, and will provide an updated PRN MAR. A copy will provided to LPA Rico.

Official classification

Type A

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 3 out of the 6 residents had full bedrails which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/27/2025 Plan of Correction Licensee stated the facility will remove bedrails and will train staff on the regualtion cited aboved. LPA Rico will be given a copy of training, and proof of removal.

Official classification

Type A

Official code

87307(a)

Regulation authority

CCR

What the official deficiency says

87307(a) Personal Accomodation and Services (a) Living accomdation and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the resident, staff and others who may reside in the facility 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 by having S1 sleep in R1's master closet which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/27/2025 Plan of Correction Licensee stated they will remove the mattress and will train staff on the regulation cited above. A copy will be provided to LPA Rico.

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 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

POC Due Date: 01/31/2025 Plan of Correction Licensee stated they will conduct an emergency drill and will provided a copy to LPA Rico.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

87309 Storage Space (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. This requirement is not met as evidenced by: Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that the multiple bottle of chemicals under the sink were locked which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee immediately removed and locked the multiple bottles of chemicals under the sink during the visit. Plan of Correction (POC) cleared. Licensee stated to train all staff on CCR 87309(a) and submit proof of training log to LPA Brown on POC due date.

Deadline recorded: Aug 18, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(d)(3)

Regulation authority

CCR

What the official deficiency says

87355(d)(3) The licensee shall submit these fingerprints to the California Department of Justice, along with a second set of fingerprints for the purpose of searching the records of the Federal Bureau of Investigation, or comply with Section 87355(c), prior to the individual's employment, residence, or initial presence in the facility. This requirement is not met as evidenced by: Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Staff #3 (S3) obtain a criminal background clearance prior to employment which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee stated to remove Staff #3 (S3) at the facility today and submit an updated Personnel Summary (LIC500) without S3 on schedule to LPA Brown on POC due date. Licensee stated to obtain S3 criminal background clearance before allowing S3 to work back at the facility.

Deadline recorded: Aug 25, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(c)(4)(A)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Demetia (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. (A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision. This requirement is not met as evidenced by: Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that there's a staff scheduled to work the shift, awake and on duty as required for facility with dementia residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee stated to submit an updated staff schedule/Personnel Summary (LIC500) showing that there's a night shift staff working at the facility, awake and on duty to LPA brown on Plan of Correction (POC) due date.

Deadline recorded: Aug 25, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87355(e)(3)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by: Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Staff #2 (S2) criminal background clearance was transferred at the facility prior to employment which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee stated to transfer S2 criminal background clearance to the facility and submit proof to LPA brown on POC due date.

Deadline recorded: Sep 3, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (5) 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 This requirement is not met as evidenced based on observation and interview, the licensee did not comply with the section cited above evidenced by removing the resident R1, R2, R3, & R4 medications out of their originally received prescription containers and storing the resident’s medications in a plastic container cups which poses an immediate health, safety, or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/17/2024 Plan of Correction The licensee has agreed to read regulation 87465 entirely and send LPA a statement of understanding that the regulation was read and understood. The licensee has agreed that moving forward the resident’s medications will be stored in the original received prescription containers. The licensee has agreed to conduct a medication training with the staff and send LPA proof of attendance. POC is due by 2/17/2024.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

87506. Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. Based on interview, observation, and document review the licensee did not comply with the section cited above evidenced by not having a resident file for resident R1, R2, and R3 in the facility which poses a potential health, safety, or personal rights risk to persons in care

Official plan of correction

The licensee has agreed to read regulation 87506 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to create a file for resident R1, R2, and R3 with all the required documents listed in regulation 87506. The POC is due by 11/17/2023.

Deadline recorded: Nov 17, 2023. 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

87412 Personnel Records (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: Based on interview, observation, and document review the licensee did not comply with the section cited above evidenced by not having a staff file for staff S1 and S2 in the facility which poses a potential health, safety, or personal rights risk to persons in care

Official plan of correction

The licensee has agreed to read regulation 87506 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to create a file for staff S1 and S2 with all the required documents listed in regulation 87412. The POC is due by 11/17/2023.

Deadline recorded: Nov 17, 2023. A deadline is not proof that correction was completed.