CHANTILLY LACE MANOR II

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPAs observations, the licensee did not comply with the section cited above by staff#1(S1) and staff#3 (S3) did not have a health screening with tuberculosis results on file. Staff#2 (S2) did not have a health screening on file; which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/13/2026 Plan of Correction The Licensee shall provided documentation of health screening with tuberculosis results for S1 and S3. The licensee shall provide documentation of health screening for S2 to the licensing agency.

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 LPAs observations, the licensee did not comply with the section cited above by staff #3 (S3) did not have a First Aid/CPR certification on file; which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/13/2026 Plan of Correction The Licensee shall provide documentation of first aid/CPR certification/training to the licensing agency.

Official classification

Type B

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPAs observations the licensee did not comply with the section cited above by Resident #1 (R1) and Resident #2 (R2) medication records were not accurately maintained by staff when compared to medication given; which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/13/2026 Plan of Correction The Licensee shall retrained staff on medication management training. Training documentation shall include the name of the trainer, names of staff with signatures, attending the training.

Official classification

Type B

Official code

1569.695(a)(2)

Regulation authority

HSC

What the official deficiency says

(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPAs observations, the licensee did not comply with the section cited above by the facility does not have enough emergency food and water for 72 hour emergency. which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/13/2026 Plan of Correction Licensee shall submit proof of purchase or pictures of the items for the 72-hour emergency food and water.

Official classification

Type B

Official code

87506(d)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records (d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours...this requirement is not met as evidence by: The Licensee did not comply with the section cited above by LPAs not having access to residents files which contain admissions agreement and physician's reports and resident registry during visit. Staff stated they did not have access to the files; which is a potential health, safety and personal rights risk to persons in care.

Official plan of correction

The Licensee/Administrator shall read and submit a statement of understanding of regulation cited to the licensing agency by POC due date.

Deadline recorded: Oct 29, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(d)(3)

Regulation authority

CCR

What the official deficiency says

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to 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: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observations, the licensee did not comply with the section cited above by not maintaining a medication administration record/log; which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/10/2025 Plan of Correction The Licensee shall submit a statement of understanding of regulation cited to the licensing agency by POC due date.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA record review, the licensee did not comply with the section cited above by not maintaining a physical health record for S1, S2, S3 for review; which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/10/2025 Plan of Correction The Licensee shall submit documentation of staff's good physical health standing to the Licensing Agency by POC due date.

Official classification

Type B

Official code

87308(c)

Regulation authority

CCR

What the official deficiency says

(c) General storage space shall be maintained for equipment and supplies as necessary to ensure that space used to meet other requirements of these regulations is not also used for storage. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observations, the licensee did not comply with the section cited above by storing facility supplies in resident's private closet; which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/10/2025 Plan of Correction The Licensee shall submit to the licensing agency documentation of facility supplies removed to the Licensing Agency by plan of correction date.

Official classification

Type B

Official code

87413(a)(1)

Regulation authority

CCR

What the official deficiency says

(1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observations; the licensee did not comply with the section cited above by fill-in staff was not sure of facility's medication record management; which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/10/2025 Plan of Correction The Licensee shall provide staff training of medication record management to the licensing agency by POC due date.

Official classification

Type B

Official code

87507(c)

Regulation authority

CCR

What the official deficiency says

(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation, the licensee did not comply with the section cited above by authorized persons signatures missing on R1's admissions agreement documents; which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/10/2025 Plan of Correction The Licensee shall submit documentation of completed and signed resident's admissions agreement to the Licensing Agency by POC due date.

Official classification

Type B

Official code

87468.2(a)(1)

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(1)To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observations, the licensee did not comply with the section cited above by having cameras in resident's bedrooms; which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/10/2025 Plan of Correction The Licensee shall submit proof to the licensing agency of cameras removed from client bedrooms by POC due date

Official classification

Type B

Official code

87470(c)(1)

Regulation authority

CCR

What the official deficiency says

(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1) The Infection Control Plan shall include all of the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above in submitting a complete Infection Control Plan which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/02/2024 Plan of Correction Licensee states that she will review and submit a complete Infection Control Plan to LPA via email by POC due date.

Official classification

Type B

Official code

87465(h)(4)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above by storing expired medication and accepting medication with altered labels which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/02/2024 Plan of Correction Licensee states that she will discard the expired medication and deny any altered label medications. Licensee will conduct a training with staff and submit proof to LPA via email by POC due date.

Official classification

Type B

Official code

87465(c)(3)

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: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in not maintaining a log for two different PRN medications for two different residents which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/02/2024 Plan of Correction Licensee states that she will train staff on the regulation cited above and submit a statement of understanding to LPA via email by POC due date.

Official classification

Type B

Official code

1569.695(d)

Regulation authority

HSC

What the official deficiency says

(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary. 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 maintaining a complete Emergency Disaster Plan which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/02/2024 Plan of Correction Licensee states that she will review and submit a complete Emergency Disaster Plan to LPA via email by POC due date.

Official classification

Type B

Official code

87265(d)(3)

Regulation authority

CCR

What the official deficiency says

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to 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: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement was not met as evidenced by: LPAs inspected resident medications and centralized record and found three medications not listed on the centralized record. Two of three medications appeared to have been administered, which poses a potential health and safety risk to clients in care.

Official plan of correction

Licensee shall conduct an audit of all resident medications and complete a completed list of all resident medications. Licensee shall submit proof of correction to the Department no later than end of POC date.

Deadline recorded: Feb 2, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (c)(1) & (f) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. (f) all personnel, including the licensee and administrator , shall be in good health... This requirement was not met as evidenced by: Based on file review, the Licensee did not ensure that all employees file has proof of first aide training and TB test, which poses a potential health, safety, personal rights violations to persons in care.

Official plan of correction

Licensee shall submit proof of all employees first aide trainings and health screening to the regional office by the POC due date.

Deadline recorded: May 15, 2023. A deadline is not proof that correction was completed.