BRASWELL'S MEDITERRANEAN GARDENS

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b): shall prior to working... in a licensed facility: (2) obtain a California clearance... as required by the Department. The requirement is not met as evidence by Based on observation the license did not ensure staff properly obtained background check/ criminal record clearance prior to being hired at the facility which poses an immediate health and safety risk.

Official plan of correction

Licensee will immediately have staff submit a criminal background clearane request to the state licensing and associate all staff to facility profile on Guardian. Once approved Licensee will submit proof of copy via email.

Deadline recorded: Mar 11, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

(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. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observations the facility staff did not ensure medications were not transferred between containers which pose potential health, safety and personal rights risk to residents in care.

Official plan of correction

POC Due Date: 12/08/2023 Plan of Correction The licensee has agreed to provide training to all staff members (Med Tec) and provided a statement of understanding of the cited regulation by the POC date of 12/8/23.

Official classification

Type B

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's observations the facility staff did not ensure MARS were siged at the time medications were given to the residents in care which pose potential health, safety and personal rights risks to resident in care.

Official plan of correction

POC Due Date: 12/08/2023 Plan of Correction The licensee has agreed to provide training to all staff members (Med Tec) and provided a statement of understanding of the cited regulation by the POC date of 12/8/23.

Official classification

Type B

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities- (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: The licensee did not ensure the personal rights of all residents were maintained. Based on interviews conducted, R1's personal rights were violated when S1 did not accord them dignity in medication administration. This poses a potential health, safety, and personal rights risk to residents in care.

Official plan of correction

AD Miller states the facility will conduct training with all staff regarding the requirement to maintain the dignity of all residents in care. Proof of training to be submitted to CCL by 5PM 6/23/2023.

Deadline recorded: Jun 23, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities-(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This regulation was not met as evidenced by: The licensee did not ensure the personal rights of all residents were maintained. Based on LPA's observation and statement of S1, S1 did not grant R1 and R2 dignity during S1's assistance with R1 and R2's toileting needs. This poses an immediate health, safety, and personal rights risk to residents in care.

Official plan of correction

The licensee with retrain all staff on the resident's right to be treated with dignity. Proof of training to be provided by 5PM 3/4/2023.

Deadline recorded: Mar 4, 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- (a) A plan for incidental medical and dental care shall be developed... The plan shall ...provide for assistance...with the following:(1)The licensee shall arrange...for medical care... appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: The licensee did not ensure medical care was arranged for the needs of R1. Based on interviews conducted, provisions for medical care were not made for R1 following their fall on 11/7/2020. The facility only made arrangements for such care two days later after being instructed to do so by R1's Conservator. This poses an immediate health,

Official plan of correction

The licensee will conduct training with all staff regarding the requirement for the arrangement of a medical evaluation following a threat to the health and/or safey to any resident. Proof of training to be submitted to CCL by 5PM 3/1/2023. (continued from left) safety, and personal rights risk to residents in care.

Deadline recorded: Mar 1, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements- (a) Each licensee shall furnish...reports...including ...the following:(1)A written report shall be submitted to the licensing agency and to the person responsible for the resident... of the occurrence of...(D) Any incident which threatens the welfare, safety or health...of any resident. This requirement was not met as evidenced by: The licensee did not ensure a written report was submitted to R1's Conservator. Based on interviews conducted, the facility notified R1's foster mother of R1's fall but not their Conservator. This poses a potential health, safety, and personal rights risk to residents in care.

Official plan of correction

The licensee will conduct training with all staff regarding the requirement for all incidents to be reported in writing to CCL as well as the resident's responsible party following any incident which threatens the health and/or safety of any resident. Proof of training to be submitted to CCL by 5PM 3/10/2023.

Deadline recorded: Mar 10, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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. This requirement was not met as evidenced by: The licensee did not ensure the facility was safe and sanitary at all times. Based on interviews conducted and records reviewed, the facility has experienced an ongoing battle with bed bugs but did not take action to mitigate bed bugs until October 2022. This poses a potential health, safety, and personal rights risk to residents in care.

Official plan of correction

The facility will submit a detailed plan of action, including the use of the services of an exterimator, for the mitigation of bed bugs once an outbreak is identified. All staff will be trained of the plan. Proof of the plan and training to be provided to CCL by POC due date.

Deadline recorded: Mar 10, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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. This requirement was not met as evidenced by: Based on interview and records reviewed, the Licensee failed to ensure the facility was sanitary at all times. Records reviewed, indicated the facility was receiving treatment for rodents and insects but not bed bugs. This is a potential health, safety, and personal rights risk to residents.

Official plan of correction

The facility will submit a detailed plan of action, to include the use of the services of an exterimator, for the mitigation of bed bugs once an outbreak is identified. All staff will be trained of the plan. Proof of the plan and training to be provided to CCL by POC due date.

Deadline recorded: Mar 10, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87507(f)

Regulation authority

CCR

What the official deficiency says

Admission Agreements- (f)The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement was not met as evidenced by: The licensee did not comply with the terms in R1's admission agreement. R1's admission agreement indicated R1 paid a monthly fee to be provided assistance with ADLs which included bathing. Interview with AD revealed AD believed bathing assistance for R1 was not required, therefore would only get it when time permitted and free of charge. This poses a potential health, safety and personal rights risk to residents in care.

Official plan of correction

The licensee will conduct training with all staff regarding the required services to be provided in each resident's admission agreement. Proof of training to be submitted to CCL by 5PM 3/10/2023.

Deadline recorded: Mar 10, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements. The licensee shall send a written report, within seven days, to the licensing agency and the person responsible for the resident when any incident occurs which threatens the welfare, safety or health of any resident. This requirement is not met as evidenced by: Licensee to ensure that all unusual incidents are reported to CCL within 7 days as specified on code section 87211. hospitalization of R#1.

Official plan of correction

Licensee to ensure that all unusual incidents are reported to CCL within 7 days as specified on code section 87211. Licensee to conduct an in-service training on reporting and writing an incident report. Evidence of in-service training must be submitted to CCL by POC date.

Deadline recorded: Jan 4, 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 the 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... This requirement is not met as evidenced by: The licensee didn't ensure staff had proper training on observation of residents in care.

Official plan of correction

*The is an amended document originally delivered on 12/28/2022* The licensee will provide traing to all direct care staff members on regulation cited 87466. The licensee will also have the resident (R1) reassessed by a physician to determine if a fall plan care plan is needed. If a it is determined that addititional care is needed per the phycians orders a copy of the new appraisal/needs and service plan will need to be forward to LPA Allen. 4/1/2023.

Deadline recorded: Mar 24, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

HSC

What the official deficiency says

This requirement is not met as evidenced by: Deficient Practice Statement (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: Based on interview and record review, the licensee did not comply with the section cited above as LPA confirmed on Guardian that Staff 1 and Staff 2 did not have criminal clearance to work at the facility which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/15/2022 Plan of Correction Licensee shall submit a Criminal Record Clearance to Community Care Licensing for Staff 1 and Staff 2 by the Plan of Correction (POC) date of 11/15/2022. Proof of submission to be submitted to LPA Allen by end of POC day.

Official classification

Type A

Official code

80072(a)(2)

Regulation authority

HSC

What the official deficiency says

Personal Rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs... This requirement was not met by: Based on records review and interviews, the Licensee did not comply with the above regulation with at least two staff trained to use Hoyer Lift to assist Resident #1 with ADL's and the resident's care plan . This is an immediate Health and Safety risk to residents in care.

Official plan of correction

Licensee agreed to have all staff providing care to residents trained on Hoyer Lift and understanding and abiding by resident’s care plans. Acknowledgement and proof of training will be provided to LPA Delgado by the requested date.

Deadline recorded: Feb 25, 2022. A deadline is not proof that correction was completed.