BRASWELLS YUCAIPA LEISURE MANOR

Official classification

Type A

Official code

87307(a)

Regulation authority

CCR

What the official deficiency says

87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy... This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by having client 1's bed, wheelchair and night stand blocking the exit door of bedroom 5 which poses a potential health, safety and or personal rights risk to persons in care.

Official plan of correction

Administrator has agreed to do an all staff inservice training and read over the entire regulations, remove all equiptment from the exit way of room 5 to ensure emergency exits are clear of obstruction. Licensee will provide pictures and the completed sign in staff training sheet via email to LPA by POC date.

Deadline recorded: Aug 12, 2026. 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(a)In addition to the rights listed in Section 87468.1... residents...shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs...delivered by staff that are sufficient in numbers, qualifications, and competency...This requirement is not met as evidenced by: R1 sustained an unwitnessed fall around 4:30pm on 8/13/22. It was not until around 11:30 am on 8/14/22, when R1 received medical care to meet R1 injuries (needs). Licensee did not ensure that R1 received care and supervision to meet R1 needs. On 8/13/2022, R1 was left unattended by staff in the dining room, for an unknown period of time. R1 sustained multiple fractures and skin tears. Medical records indicate the cause of the injuries was a fall. This posed an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

The Licensee/Administrator has a agreed to conduct inservice training on regulation cited an provided documentation of training to the Licensing Agency by POC due date.

Deadline recorded: Jun 26, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

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...functioning... appropriate assistance is provided when such observation reveals unmet needs. When changes such as...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 is not met as evidenced by: Staff observed R1 with skin tears, unable to sit up without pain and did not notify R1 physician regarding changes in the R1's condition. This posed an immediate health, safety, and personal risk to residents in care.

Official plan of correction

The Licensee/Administrator has a agreed to conduct inservice training on regulation cited an provided documentation of training to the Licensing Agency by POC due date.

Deadline recorded: Jun 26, 2025. 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 is not met as evidenced by: Staff received disciplinary action for not appropriately/immediately reporting falls and injuries (condition) to R1's authorized party and physician. Admissions agreement reveals basic services includes, " monitoring and appropriate reporting of resident needs and conditions to family and physician " . This posed a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

The Licensee/Administrator has agreed to provide inservice training on regulation cited and submit documentation of training to the licensing agency by POC due date.

Deadline recorded: Jun 26, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87625(b)(3)

Regulation authority

HSC

What the official deficiency says

87625 Managed Incontinence (b) In addition to Section 87611, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by: Based on LPAs observations staff did not change resident's pull ups in a timely manner. LPAs observed resident soaked in adult pull up which poses a health and safety risk to residents in care

Official plan of correction

Administrator told staff to change resident adult pull ups while LPAs was at the facility. LPAs recommended facility maintain a incontinence log for residents and email log to LPA by Plan of Correction (POC) due date

Deadline recorded: May 15, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above due to the assisted living wing rooms 21 and 28 hot water measured at 138.5 and 145.2, along with memory care shower hot water temperature measured at 145.9 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/08/2025 Plan of Correction Administrator called a maintenance technician to adjust the water temperature and will be sending LPA proof of hot water adjustment by POC due date.

Official classification

Type A

Official code

87468.1

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities-(a) Residents...shall have all of the following personal rights: (11) To have their visitors...permitted to visit privately during reasonable hours... provided... rights of other residents are not infringed upon. 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, ED prohibited in person visits for R1. This poses an immediate personal rights risk to residents in care

Official plan of correction

The licensee will submit a written statement of understanding of the regulation cited by POC due date.

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

Official classification

Type A

Official code

87468(a)(16)

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:(16)To receive or reject medical care or other services. This requirement was not met as evidenced by: The licensee did not ensure the personal rights of all residents were maintained. Based on interviews, ED confirmed she canceled R1's medical appointment because R1's family was going to accompany them to the appointment. This poses an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

The licensee will submit a written statement of understanding of the regulation cited by POC due date.

Deadline recorded: Aug 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 person responsible for the resident within 7 days of..occurrence of any...events specified...below. (D)...unexplained absence of any resident. This requirement was not met as evidence by: The licensee did not ensure R1's responsible party was notified of an unexplained absence. Based on interviews and records reviewed, ED denied R1 had an unexplained absence yet records reviewed indicated R1 may have been unaccounted for. This poses a potential

Official plan of correction

The licensee will submit proof of staff training of the regulation cited by POC due date. (con't. from right) health, safety, and personal rights risks to residents in care.

Deadline recorded: Aug 11, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)

Regulation authority

CCR

What the official deficiency says

Additional Personal Rights of Residents in Privately Operated Facilities- (a) In addition to...Section 87468.1... residents in...residential care facilities for the elderly shall have...the following personal rights:(4)To care, supervision...by staff ...to meet their needs. This requirement was not met as evidenced by: The licensee did not ensure the personal rights of all residents were maintained. Based record review, the supervision of R1 had been unverified as reported in an incident reported dated 2/28/20. This poses an immediate health, safety, and personal rights risk to residents

Official plan of correction

The licensee will submit proof of staff training of the regulation cited by POC due date. *The due date is flexible to complete this training. (con't. from left) in care.

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

Official classification

Type B

Official code

87207

Regulation authority

CCR

What the official deficiency says

87207 False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.This requirement is not met as evidenced by: The licensee did not ensure that staff members understand that False Claims of any kind are not acceptable. The interviews conducted, and documents reviewed show that someone a (licensee, officer or employee of a licensee) falsified medical documents that were not signed by an licensed medical professional.

Official plan of correction

POC- The licensee has agreed to provide training to all staff regarding the cited Regulation 87207 and Health and Safety codes. Licensee has agreed that they will provide a statement of understanding signed by all staff members confirming that they have read and understand the regulation 87207 and Health and Safety codes. Health and Safety codes NOTE: Authority cited: Section 1569.30, Health and Safety Code. Reference: Section 1569.44, Health and Safety Code. By the POC 5/19/2023.

Deadline recorded: May 19, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(d)(3)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (d) All personnel shall be given on the job training or have related experience in the ... (3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents. This requirement is not met as evidenced by: Based on interviews with S1 & S3, the licensee did not ensure that R1 was provided adequate supervision. This is a potential health and safety risk to residents in care.

Official plan of correction

The Administrator agreed to conduct training on regulation 87411 and send proof of training (roster with date and names) to the Department by POC date of 7/27/2021.

Deadline recorded: Jul 27, 2021. A deadline is not proof that correction was completed.