PEACE AND JOY RCFE

Official classification

Type A

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 in 1 out of 1 times which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/10/2024 Plan of Correction The Licensee agrees to conduct an emergency disaster drill to satisfy the required quarterly drills. Proof of POC is to be submitted to the department by 5pm on the due date indicated.

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

87203 Fire Safety - All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic This was not met because the smoke alarm was missing from the a residents room #2.

Official plan of correction

Administrator will purchase and replace missing smoke alarm by 12/27/2021. Licensee will submit a photograph as proof of compliance by due date.

Deadline recorded: Dec 27, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(j)

Regulation authority

CCR

What the official deficiency says

Care of Persons with Dementia. The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This was not met by; the facility failed to use the auditory alarm as designed. All auditory alarms had been turned off and doors were left ajar during visit.

Official plan of correction

The administrator will provide training on the proper care of persons with Dementia.

Deadline recorded: Dec 23, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(H)(2)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care.The following requirements shall apply to medications which are centrally stored:Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This was not met because medication were left unatended/ not locked on main floor accessible to dementia residents.

Official plan of correction

The administrator will be sure to have all medications secured inacessible to residents at all time.

Deadline recorded: Dec 24, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(6)(D)

Regulation authority

CCR

What the official deficiency says

Incidental Medical & Dental Assistance with self-administration does not include forcing a resident to take medication, hiding or camouflaging medications in other substances without the resident's knowledge and consent, or otherwise infringing upon a resident's right to refuse to take a medication. The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: The LPA observed a pill crusher inservices without perscription or authorization for use.

Official plan of correction

The facility will remove any pill crusher or cutter unless there is a physician authorization or precription.

Deadline recorded: Dec 31, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation 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 was not met because, LPA observed several tiles that were broken near the kitchen.

Official plan of correction

The administrator will repair or replace broken tiles through out the facility by 12/31/2021

Deadline recorded: Dec 31, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87406(a)

Regulation authority

CCR

What the official deficiency says

Administrator - Qualifications and Duties.All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This was not because LPA observed that the administrators certificate was expired during visit.

Official plan of correction

The administrator will submit proof of correction by due date 12/31/2021.

Deadline recorded: Dec 31, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87305(a)

Regulation authority

CCR

What the official deficiency says

Alterations to Existing Building or New Facilities. Prior to construction or alterations, all facilities shall obtain a building permit. LPA observed additional rooms in the garage being used as living quarters.

Official plan of correction

Licensee will submit proof that rooms mentioned in garage were permitted by city code by due date 12/31/2021.

Deadline recorded: Dec 31, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(D)(1)

Regulation authority

CCR

What the official deficiency says

Administrator - Qualifications and Duties The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (1) Knowledge of the requirements for providing care and supervision appropriate to the residents. The LPA observed that the facility was using a hoyer lift without proper documented training or without proper instuction from a licensed proessional.

Official plan of correction

The licensee will remove or seek training for the equipment used for the residnets needs by due date. 12/31/2021

Deadline recorded: Dec 31, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can 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: Once ordered by the physician the medication is given according to the physician's directions. This was not met because the facility could not prove that the medication was dispensed as per physicans instructions.

Official plan of correction

The licensee will provide training to all staff regarding proper dispensing of medication by 12/31/2021.

Deadline recorded: Dec 31, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

CCR 87632(a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department. This requirement was not met as evidenced by: Based on interview, and record interview, licensee failed to ensure an approved hospice waiver was in place upon retaining a resident on hospice. This poses an immediate health and safety to residents in care.

Deadline recorded: Aug 31, 2021. A deadline is not proof that correction was completed.