ESKATON GOLD RIVER LODGE

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by:Administrator, LPA and Regional manager observed medication unlocked in two residents rooms that administer their own medications. Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in 2 of 4 rooms inspected which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/18/2025 Plan of Correction The facility will reassess R1 and R2 for self administration of their medication including keeping medication locked and not accessible to others.

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above when the LPA observed a sharp 6 inch serrated knife in a memory care kitchenette cabinet and when she observed scissors in kitchenette drawer. These items posed/poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/12/2024 Plan of Correction Designated Facility Administrator immediately removed prohibited items and has stated they will do daily checks of the common areas in memory care which will be logged. This log template will be submitted by 6/13/24 close of business and the logs themselves will be submitted to kimberly.viarella@dss.ca.gov by 6/20/24.

Official classification

Type B

Official code

1569.625(b)(1)

Regulation authority

HSC

What the official deficiency says

(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: Deficient Practice Statement Based on record review and an interview with the Facility Administrator, the licensee did not comply with the section cited above as observed by they LPA during a review of staff files. In 2 of the 3 staff files, there was no proof of initial training documented. This posed a potential threat to the health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/11/2024 Plan of Correction Designated Facility Administrator stated that he will provide an audit of all missing training for care staff and med techs and will also update Eskaton Academy materials to provide regulation references. This information will be submitted to kimberly.viarella@dss.ca.gov by 7/11/24.

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 a records a review and an interview with the Designated Facility Administrator, the licensee did not comply with the section cited above when 2 out of 3 staff files were missing required annual training components. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/30/2024 Plan of Correction Designated Facility Administrator stated that he will provide an audit of all missing training for care staff and med techs and will also update Eskaton Academy materials to provide regulation references. This information will be submitted to kimberly.viarella@dss.ca.gov by 7/11/24.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Deficient Practice Statement Based on a records review and interview with the Designated Facility Administrator, the licensee did not comply with the section cited above when 2 out of 3 staff files reviewed staff did not have a current first aid/CPR certification. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/11/2024 Plan of Correction The Designated Facility Administrator stated he will have all care staff /medtechs First Aid/CPR certified by 07/11/24. Copies of certifications will be submitted to kimberly.viarella@dss.ca.gov.

Official classification

Type A

Official code

873559(e)

Regulation authority

CCR

What the official deficiency says

e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review and interview with the Designated Facility Administrator, the licensee did not comply with the section cited above when a minor hired to work as a server turned 18 last summer and the licensee did not obtain a background check clearance for them. This posed / poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/12/2024 Plan of Correction Facility sent the staff member to be fingerprinted and they will not return to work until they have been cleared. THis POC has been cleared. As follow up, proof of clearance will be sent to kimberly.viarella@dss.ca.gov.

Official classification

Type A

Official code

87355(e)(3)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c)... This requirement is not met as evidenced by: Deficient Practice Statement Based on a record review and an interview with the Business Office Manager, the licensee did not comply with the section cited above when 4 employees transfered to this facility but requests for them to be associated were not completed. This posed / poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/12/2024 Plan of Correction These transfer requests have been completed. This POC has been cleared.

Official classification

Type A

Official code

87355(e)(3)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: Plan of Correction

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

Personnel Requirements – General: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement was not met as evidenced by staff actions when encountering a known resident’s dog unattended, no staff member checked on resident for over 20 minutes prior to being discovered in the front of the building and did not display competency in their job performance by not checking on resident who was in a stated of distress which poses an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

Facility had agreed to conduct emergency response training with staff and document the proceedures in place all staff members must follow including steps and actions each staff member is required to make when a resident is experiencing a medical emergency. Procedures and trinaing material will be provided by the POC due date.

Deadline recorded: Nov 17, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87466

Regulation authority

CCR

What the official deficiency says

Observation of Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional, and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidenced by statements by facility and outside care providers and documentation of concerns of Resident cognitive decline prior to the last resident care meeting with authorized provider and the resident’s death which poses a potential health, safety, and personal rights risk for residents in care.

Official plan of correction

LPA and facility discussed the development of a " red flag " system where by a resident with an observed change in condition is red flagged by a staff member onthe community board and thus alerting all staff members. the red flag notice will remain on the resident's board untill re-evluated by a physician or teh care plan is changed to reflect additional resident needs for care and supervision.

Deadline recorded: Nov 30, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by LPA's interviews with staff and self reported incident report that details how resident was given and incorrect dose of acetaminophen on 6/25/23 when the medication was provided two hours before the next scheduled dose, which poses an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

Facility has conducted retaining of the staff member including staff shaddowing and are in process of reevaluating annual ongoing training for medication staff.

Deadline recorded: Jul 13, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by LPA's interviews with staff and self reported incident report that details how resident was given and incorrect dose of insulin on 6/9/23 when no insulin should have been provided to the resident which poses an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

LPA and Administrator together developed a POC: The facility will provide a written plan of correction regrading changes to the administration of insulin: including but not limited to the development of a mobile insulin MAR where documentation of the recorded blood glucose is documented and recorded prior to drawing insulin or assisting residents with self administration of insulin.

Deadline recorded: Jun 22, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by LPA's interviews with staff and self reported incident report that details how resident was given and incorrect doses of insulin on 4/16 and 4/26 which poses an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

Facility will conduct medication administration retaining for both staff members responsible for medication errors and will provide the department with a written explanation of the new medication administration process for insulin for all residents.

Deadline recorded: May 5, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87463(c)

Regulation authority

CCR

What the official deficiency says

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by: Deficient Practice Statement Based on the review of 11 resident files, the licensee did not comply with the section cited above in 1 out of 11 resident files reviewed where the LIC 602 physician's report was not updated annualy per regualtions which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/05/2023 Plan of Correction facility will provide a written plan of correction providing the specific practices that will be incorportated into the facility operation to ensure all residents with a diagnosis of dementia are reassessed every 12 months.

Official classification

Type A

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

Incidental Medical and Dental Care: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by LPA's interviews with staff and self reported incident report that details how resident was given and additional dose of weekly medication which poses an immeated health, safety and personal rights risk to residents in care.

Official plan of correction

Facility will provide the department with documentation of retaining for staff member who administered incorrect medication.

Deadline recorded: Jan 5, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87463(a)(2)

Regulation authority

CCR

What the official deficiency says

Reappraisals: The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: A mental/social trauma such as the loss of a loved one. This requirement was not met as evidenced by facility staff did not arrange for R1 to be reappraised after being informed of R1’s statements of suicidal ideation on 5/14/22 which poses an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

The facility has agreed To provide training for staff to ensure staff member report instances of residents threatening self harm. Facility will also develop additional screening and reappraisals for any resident struggling with mental health or any change in condition.

Deadline recorded: Sep 6, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

Additional Personal Rights of Residents in Privately Operated Facilities: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by facility did not provide enhanced safety checks for resident who expressed suicidal ideation on 5/14/22 resulting in resident committing suicide on 5/30/22 which poses an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

the facility has agreed to provide detailed steps facility will take including companionship and supervision including linkages with family/friend support in conjunction with the a resident's primary care physician and referral to a psychiatric services in the event of a resident expressing suicidal ideation.

Deadline recorded: Sep 6, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(g)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care: The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement was not met as evidenced by when staff discovered R1 the staff did not immediately contact 911 for emergency services and instead sought additional support from additional facility staff which may have delayed first responders from initiating timely aid to the resident which poses an immediate health, safety and personal right risk to residents in care.

Official plan of correction

The facility has agreed to provide training for all facility staff on emergency procedures and provide LPA with a copy of training materials and documentation that all staff received training.

Deadline recorded: Sep 6, 2022. A deadline is not proof that correction was completed.