LITTLE BROOK CARE HOME #3

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. 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 2 out of 2 files reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/06/2024 Plan of Correction Administrator will submit proof of annual training for S1 and S2

Official classification

Type B

Official code

1569.69(a)(2)

Regulation authority

HSC

What the official deficiency says

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. 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 2 out of 2 files reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/06/2024 Plan of Correction Administrator will submit proof of initial training for S1 and S2

Official classification

Type B

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

(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: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 1 out of 5 resident files which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/06/2024 Plan of Correction Administrator to submit LIC602 for R1 by POC due date

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (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 in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on observation and documentation reviewed, the facility did not ensure the start dates for each medication were documented and a medication count could not be conducted to ensure medications are being given as prescribed, which poses an immediate health, safety, and personal rights risk to residents in care.

Official plan of correction

Licensee agrees document when each medication bottle is started for each resident and to complete a statement of understanding by the POC due date of 1/26/24.

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

Official classification

Type B

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) 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 requirement is not met as evidenced by: Based on observation, the facility did not ensure the keys were not hanging from the medication cart, which poses a potential health, safety, and personal rights risk to residents in care.

Official plan of correction

Licensee agrees to keep medication keys in a different location of the facility and will complete a statement of understanding by the POC due date 2/8/24.

Deadline recorded: Feb 8, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(h)(6)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) 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... This requirement is not met as evidenced by: Based on observation and documentation reviewed, the facility did not ensure each resident had a completed Centrally Stored Medications Form, which poses a potential health, safety, and personal rights risk to residents in care.

Official plan of correction

Licensee agrees to either complete Centrally Stored Medications Forms for each resident or update their electronic system to indicate all required information for each medication provided. Licensee agrees to submit a statement of understanding by the POC due date of 2/8/24.

Deadline recorded: Feb 8, 2024. A deadline is not proof that correction was completed.

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 record review, the licensee did not comply with the section cited above as the two caregivers on duty did not have CPR and first aid training documentation in their personnel files, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/11/2023 Plan of Correction Licensee agrees to have both caregivers complete CPR and first aid training by the POC due date of 10/11/2023. Administrator/Licensee arrived at the facility for inspection and has a current CPR and first aid certification.