NEW HORIZONS

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2(a)(4)Additional Personal Rights of Residents in Privately Operated Facilities(4) To care, supervision, and services. meet their individual needs.. delivered by staff.. sufficient in numbers, qualifications.. to meet their needs.This requirement is not met as evidenced by: Based upon review of facility, records, observations, and interviews licensee failed to ensure that R1 was provided with care, supervision,services required. As a result, R1 sustained a fracture while at facility. This violation posed an immediate health and safety risk to residents in care.

Official plan of correction

The Administrator stated they conduct an in-service training for all staff members on the regulation cited. Administrator also stated they will send proof to LPA Rico. POC due date 2/12/2025

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

Official classification

Type B

Official code

87411(g)(2)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as eveidenced by: Based on observation, interview, record review, the licensee did not comply with the section cited above by not transferring Staff #10 (S10) criminal backgound clearance to the facility prior to employment which pose potential health, safety and personal rights risks to residents in care.

Official plan of correction

Licensee stated to transfer S10 Criminal Background Clerance to the facility or submit a Criminal Background Clearance Transfer Request form (LIC9182) for S10 and submit proof to LPA Brown on Plan of Correction (POC) due date.

Deadline recorded: Dec 6, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

87465 Incidental & Medical Services (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance...(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Based on observation, interview, record review, the licensee did not comply with the section cited above by not updating Resident #1 (R1) Medication Administration Record (MAR) when dispensing R1 medications from 07/01/2024 to 07/15/2024 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee stated to train all staff in CCR 87465(a)(6) and submit proof of Training Log to LPA Brown at Plan of Correction (POC) due date.

Deadline recorded: Jul 9, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do...(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (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: Based on observation, interview, record review, the licensee did not comply with the section cited above by having a full bed rail for Resident #1 (R1) and R1's not on hospice and no exception was submitted and approved to CCLD which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee stated to remove R1's full bed rail and submit proof to LPA Brown on POC due date.

Deadline recorded: Jul 16, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by: Based on observation, interview, record review, the licensee did not comply with the section cited above by not having a completed Physician Report with Physician Signature Date for Resident #1 (R1) which poses an immeidate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee stated to submit a copy of R1's completed Physician Reports with Physician Signature Date to LPA Brown on Plan of Correction (POC) due date.

Deadline recorded: Jul 16, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

87608 Postural Supports (a) Based on the individuals preadmission appraisal....(3) A written order from a physician indicating the need for the postural support shall be maintained in the residents record. The licensing agency... 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 having Resident #2 (R2), Resident #3 (R3), Resident #4 (R4), Resident #8 (R8), Resident #9 (R9), Resident #10 (R10) with half bed rails with no written order from their physician indicating the need for the postural support for mobility which poses a potential health, safety and personal rights risks to resident in care.

Official plan of correction

The Licensee stated to submit written order from R2, R3, R4, R8, R9 and R10 physician indicating the need for the postural support for mobility and submit proof to LPA Brown on plan of correction (POC) due date.

Deadline recorded: Jul 26, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(g)(2)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as eveidenced by: Based on observation, interview, record review, the licensee did not comply with the section cited above by not transferring Staff #8 (S8) and Staff #9 (S9) criminal backgound clearance to the facility prior to employment which pose potential health, safety and personal rights risks to residents in care.

Official plan of correction

Licensee submitted S8 and S9 Criminal Background Clerance Transfer Request forms (LIC9182) to LPA Brown during the visit. Plan of Correction (POC) cleared.

Deadline recorded: Jul 26, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(j)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and observation, the licensee did not comply with the section cited above evidenced by not having auditory devices on the facility exits which poses a potential health, safety, or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/04/2023 Plan of Correction The licensee has agreed to read regulation 87705 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to install auditory devices on all facility exits. POC is due by 12/4/2023.

Official classification

Type A

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia(c)Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) 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. Based on interview and document review, the licensee did not comply with the section cited above evidenced by not completing an annual medical assessment and reappraisal for Resident R1 which poses an immediate health, safety, or personal rights risk to persons in care.

Official plan of correction

The licensee has agreed to read regulation 87705 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to ensure R1 has the required assesments completed. The licensee has agreed that moving forward all dementia care residents will have a medical assessment and reappraisal completed annually. The POC is due by 9/7/2023.

Deadline recorded: Sep 7, 2023. A deadline is not proof that correction was completed.