SAINT THOMAS CARE HOME

Official classification

Type B

Official code

87458(c)(1)(A)

Regulation authority

CCR

What the official deficiency says

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review, the licensee did not comply with the section cited above in two out of four residents files had no record of negitive TB test which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/31/2026 Plan of Correction Administrator will have a copy of negitive TB test in all resident files. Administrator will have all residents admission agreements signed and in resident file. Administrator will notify LPA when completed.

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 LPAs' observations and records reviewed, the facility did not ensure that documentation for medication administered was complete, resulting in information missing pertaining to medication administration, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Facility will complete a statement of understanding regarding regulation 87465 and submit statement of understanding to LPA by POC due date of 8/29/2024.

Deadline recorded: Aug 29, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.625(b)(1)

Regulation authority

HSC

What the official deficiency says

§1569.625 Staff training; legislative findings; contents (b) (1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. This requirement is not met as evidenced by: Based on LPAs' observations and records reviewed, facility did not ensure that initial training was sufficient for one (1) caregiver per Health and Safety Code, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Facility will complete a statement of understanding regarding regulation 1569.625 and submit statement of understanding to LPA by POC due date of 9/12/2024.

Deadline recorded: Sep 12, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.695

Regulation authority

HSC

What the official deficiency says

§1569.695 Emergency Plans (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 notrequired 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: Based on LPAs' observations and records reviewed, facility did not ensure to document quarterly drills completed, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Facility will complete a statement of understanding regarding regulation 1569.695 and submit statement of understanding to LPA by POC due date of 9/12/2024.

Deadline recorded: Sep 12, 2024. A deadline is not proof that correction was completed.