FERN HOME III LLC

Official classification

Type B

Official code

1569.605

Regulation authority

HSC

What the official deficiency says

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. 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 by not having liability insurance which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/15/2026 Plan of Correction Administrator has agreed to purchase liability insurance and provide proof to LPA 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 [(observation) (interview) (record review)], the licensee did not comply with the section cited above by Staff #2 (S2) not having a signed health screening 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 agreed to obtain a signed health screening for S2 and provide proof to LPA by POC due date.

Official classification

Type B

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 [(observation) (interview) (record review)], the licensee did not comply with the section cited above by not having the MAR checked off after July 10th which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/22/2026 Plan of Correction Administrator has agreed to provide training for staff and provide proof of training with signatures understanding the regulation being cited to LPA by POC due date.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. 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 by not having pre admission appraisals (LIC 603/A) for Resident #1,#2, & #3 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 agreed to create and update yearly appraisals for all residents and provide proof to LPA by POC due date

Official classification

Type B

Official code

1569.695(e)(2)

Regulation authority

HSC

What the official deficiency says

(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident. 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 by not having (LIC 625) Needs and Service plans filled out for resident #1, #2, #3 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 agreed to create needs and service plans (LIC 625) for all residents and provide proof to LPA by POC due date.

Official classification

Type A

Official code

87412(a)(11)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. 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 not having a physician report for S#2 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/19/2024 Plan of Correction Administrator agreed to provide proof of health screening for Staff #2 to LPA by POC date.

Official classification

Type A

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 observation, interview, and record review, the licensee did not comply with the section cited above in not having a CPR certificate for S #2 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/19/2024 Plan of Correction Administrator agreed to provide proof of CPR certificate for Staff #2 to LPA by POC date.

Official classification

Type A

Official code

87411(c)(6)

Regulation authority

CCR

What the official deficiency says

(6) The licensee shall maintain documentation pertaining to staff training in the personnel records, as specified in Section 87412(c)(2). For on-the-job training, documentation shall consist of a statement or notation, made by the trainer, of the content covered in the training. Each item of documentation shall include a notation that indicates which of the criteria of Section 87411(c)(3) is met by the trainer. 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 by not having record of trainings for S #2 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/19/2024 Plan of Correction Administrator agreed to provide proof of trainings for Staff #2 to LPA by POC 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 file review, the licensee did not comply with the section cited above by Staff #1 (S1) health screening is incomplete which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/30/2023 Plan of Correction Administrator shall provide proof of health test result for Staff #1 to the licensing agency by POC date.

Official classification

Type B

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

87465. Incidental Medical and Dental Care. (h)The following requirements shall apply to medications which are centrally stored:(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. Based on observation, the licensee did not comply with the section cited above by pre-prepping medications and storing medications in alternative containers. The medications were not stored in the original received containers from the pharmacy which poses an immediate health, safety, or personal rights risk to persons in care.

Deadline recorded: Jun 16, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

Not listed

Regulation authority

Not listed

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. Based on observation, the licensee did not comply with the section cited above by storing medications in the refrigerator without a lock box. The medications were not locked in a box in the refrigerator which makes medications accessible to the residents in care which poses an immediate health, safety, or personal rights risk to persons in care.

Deadline recorded: Jun 16, 2022. A deadline is not proof that correction was completed.