WALNUT HOUSE

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

(c) 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: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Deficient Practice Statement Based on records review and interview with RCC, the licensee did not comply with the section cited above in 5 out of 6 MARS reviewed for R1, R2, R3, R5 and R6 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/12/2026 Plan of Correction Admin agrees to submit a plan, with timelines and responsible staff, to address MAR wording, med supply and MAR auditing, staff training and oversight of quality and a communication procedure when med techs identify meds not administered to the appropriate manager for timely correction. This POC is due by 8/12/26.

Official classification

Type B

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care (a)(4) The licensee shall assist residents with self-administered medications as needed.This requirement was not met based on records and statements with found the facility's plan was not followed for correct medication administration. This posed a potential risk.

Official plan of correction

Following the incident, S1 was removed from med passing and all med techs received retraining. Licensee will submit proof of training to CCLD by the POC date of 4/15/25.

Deadline recorded: Apr 15, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)(1)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (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. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. 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 LPA observed the shower room to have pink mildew around the floors which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/30/2024 Plan of Correction Licensee is to conduct a plan of how facility will ensure shower room floor remains clean and sanitary. Plan is to be implemented and submitted via fax/email to LPA by due date of 8/30/2024.

Official classification

Type A

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, LPA observed multiple unlocked medications in residents' rooms on 10/19/22 from 10::00 am- 3:40 pm, which poses an immediate health and safety risk to residents in care. RCC or Administrator promptly removed the unlocked medications.

Official plan of correction

Administrator agreed to ensure resident (R4) gets a locked box so he can secure the inhalers. Administrator and RCC also spoke to the family members of R2 and R4 advising that residents cannot return to the faciltiy with any medications at all. Today, there was mandatory staff training, per the Stipulation, and the topic was Medication Management. Allen Flores Consulting Group to send a copy of the Power Point and attendees to CCLD by 10/21/22.

Deadline recorded: Oct 21, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(i)(1)(B)

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation (i) facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more ... shall have a signal system which shall: (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. This requirement was not met based on records and interviews which found that on 11/18/21, R1 left the building unassisted and staff did not hear the front door alarm when R1 exited the building. This posed an immediate health and safety risk to R1.

Official plan of correction

Licensee agrees to utilize the alarm currently used for evening to be used at all times that staff are not present at or neear the front door. Licensee will submit a statement of the procedure for front door alarms to CCL by the POC date of 12/10/21. To be cleared by POC visit.

Deadline recorded: Dec 10, 2021. A deadline is not proof that correction was completed.