OCEANSIDE ELDERLY CARE HOME 448

Official classification

Type B

Official code

87506(b)(9)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records: “(b) Each resident’s record shall contain at least the following information: (9) Name, address, and telephone number of physician and dentist.” This requirement was not met, as evidenced by: Based on records and interviews, for 2 of 2 residents (R1 and R2), Licensee did not ensure that their record of care contained the name, address, and telephone number for both their respective current dentist and physician. This posed a potential health risk to persons in care.

Official plan of correction

During today’s site visit, LPA provided Licensee with the names and phone numbers for R1’s PCP and RP. Licensee agreed to update the Face Sheet for R1 to include the name, address, and telephone number for R1’s current PCP, NP, and dentist. Licensee agreed to update the Face Sheet for R2 to include the name, address, and telephone number for R2’s current dentist. Licensee agreed to E-mail the updated Face Sheets for R1 and R2 to LPA, by the POC due date.

Deadline recorded: Nov 11, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87467(a)

Regulation authority

CCR

What the official deficiency says

87467 Resident Participation in Decisionmaking: “(a) Prior to, or within two weeks of the resident’s admission, 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, and any other appropriate parties, to prepare a written record of care the resident will receive in the facility, and the resident’s preferences regarding the services provided at the facility.” This requirement was not met, as evidenced by: Based on records reviewed and manager interview, Licensee did not have on file for 2 of 2 residents (R1 and R2) a completed LIC625 Appraisal/Needs and Services Plan (or equivalent “written record of care the resident will receive”), and the resident’s preferences regarding the services provided at the facility. This posed a potential health and personal rights risks to persons in care.

Official plan of correction

Licensee agreed to complete an LIC625 Appraisal/Needs and Services Plan form on both R1 and R2, and to have both signed by their respective responsible person and a facility representative after a joint-review during a care-conference meeting. Licensee agreed to E-mail the completed and signed LIC625s for R1 and R2 to LPA, by the POC due date. Going forward, Licensee agreed to update the LIC625 and hold a care conference, for all residents, whenever there is a significant change in their condition, but also at least once every twelve (12) months, whichever occurs first.

Deadline recorded: Nov 11, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466 Observation of the Resident: “The licensee shall ensure that residents are regularly observed for changes in physical…functioning... When changes such as…deterioration of…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: Based on records and interviews, 1 of 2 residents (R1) had a deterioration of a physical health condition which staff observed, but Licensee did not ensure that this change was documented and brought to the attention of the resident’s physician (or their staff) and responsible person. This posed a potential health risk to persons in care.

Official plan of correction

Licensee agreed to contact a third-party, CCLD-approved education Vendor to arrange a retraining class. The retraining will cover Skin Care for the Elderly, 87625 Managed Incontinence, 87465 Incidental Medical and Dental Care, 87466 Observation of the Resident, 87211 Reporting Requirements, and Resident’s Personal Rights (as articulated in CCLD form LIC613C-2), and will include both Licensee principals and current facility caregivers. Licensee agreed to E-mail the certificates of training completion (or similar proof) to LPA, by the POC due date.

Deadline recorded: Nov 11, 2024. 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

87211 Reporting Requirements: " (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified...(D) Any incident which threatens the welfare, safety or health of any resident. " This requirement was not met, as evidenced by: Based on records and interviews, 1 of 2 residents (R1) had an incident which threatened their welfare/health, and Licensee did not submit a written report of the incident to the licensing agency and the person responsible for the resident within seven days of incident occurrence. This posed a potential health risk to persons in care.

Official plan of correction

Licensee agreed to contact a third-party, CCLD-approved education Vendor to arrange a retraining class. The retraining will cover Skin Care for the Elderly, 87625 Managed Incontinence, 87465 Incidental Medical and Dental Care, 87466 Observation of the Resident, 87211 Reporting Requirements, and Resident’s Personal Rights (as articulated in CCLD form LIC613C-2), and will include both Licensee principals and current facility caregivers. Licensee agreed to E-mail the certificates of training completion (or similar proof) to LPA, by the POC due date.

Deadline recorded: Nov 11, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(20)

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: “(a)…residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (20) To be protected from involuntary transfers, discharges, and evictions…‘involuntary’ means a transfer, discharge, or eviction that is initiated by the licensee, not by the resident.” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not ensure that 1 of 2 residents (R1) was protected from involuntary transfer. The transfer was initiated by the licensee, not by the resident. This posed a potential personal rights risk to persons in care.

Official plan of correction

As of the date of deficiency issuance, the responsible person (RP) for R1 has agreed with Licensee’s decision to keep R1 in their current bedroom at Oceanside Elderly Care Home 452, for the time being. Licensee agreed that if at a future point they desire for R1 to move back to Oceanside Elderly Care Home 448, they will first communicate with R1’s RP, receive their consent, and meet all regulatory requirements.

Deadline recorded: Nov 11, 2024. 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

(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 degree C) and not more than 120 degree F (49 degree 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 in that the hot water was measured at 141.5 and 143.2 degrees F in bathrooms for resident use which poses an immediate safety risk to 2 of 2 residents in care.

Official plan of correction

POC Due Date: 07/01/2024 Plan of Correction Facility staff adjusted the hot water temperature during the visit. Facility staff will conduct checks of water temperature in bathrooms every other day for a week in a written log. Administrator will submit copy of the log to the Department by POC due date of 7/1/2024.

Official classification

Type A

Official code

87465

Regulation authority

CCR

What the official deficiency says

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... This requirement was not met as evidenced by: Based on staff and outside source interviews and records reviews revealed the Licensee did not immediately telephone 911 after Resident 1 (R1) sustained an injury deemed an imminent threat to their health. This posed an immediate safety risk to [R1] 1 out of 6 residents in care.

Official plan of correction

An all staff will attend CCL approved training regarding incidents that occur that require immediate medical intervention including activating a 911 call. Proof of POC will be provided by POC due date.

Deadline recorded: Mar 28, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(A)(1)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care. A plan for...medical...care shall be developed by each facility. The plan shall ... provide...obtaining such care, compliance with...the Licensee shall arrange...medical...care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Based on interviews and records reviews the Licensee did not arrange medical care for Resident 1 (R1) that was appropriate to their condition. This posed a potential health risk to 1 out of 6 residents in care.

Official plan of correction

Facility staff will attend a CCL approved training on when to obtain or arrange medical care for residents in care based on their health, physical, or mental conditions. Licensee will provide proof of completion by POC due date. This is amended version of the report dated 02/28/2024.

Deadline recorded: Mar 28, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(e)(1-4)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care. For every prescription and... PRN medication for which the licensee provides...shall be a signed... order....and label shall contain...The specific symptoms... hours between doses... maximum...doses allowed in...24-hour. This requirement was not met as evidenced by: Based on interviews and records reviews the Licensee did not maintain a signed written order for Resident 1 [R1] in care. This posed a potential health risk to 1 out of 6 residents in care

Official plan of correction

Facility staff will attend a CCL approved training on medication management and implement a tracking system to ensure all resident's MAR are complete at the end of each shift. Licensee will provide proof of completion by POC due date.

Deadline recorded: Mar 28, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1

Regulation authority

CCR

What the official deficiency says

Residents in all residential care facilities for the elderly shall have all of the following personal rights:(11)To have their visitors, in...permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This regulation was not met as evidenced by: Based on interviews and observations Resident 1 [R1] in care was not afforded a reasonable level of visits at the facility. This posed a potential personal rights risk to [R1] 1 out of # in care.

Official plan of correction

At the time of the initial visit LPA consulted with Licensee and at the time of visit Licensee removed visitation signs from facility door. Visitation is allowed per plan of operation protocol. Deficiency is cleared. This is amended version of the report dated 02/28/2024.

Deadline recorded: Mar 28, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained ...in the facility or...central... location readily available to facility staff and to licensing agency staff. This requirement was not met as evidence by: Based in LPA's interviews and records reviews staff did not maintain complete records for Resident1. This posed a potential heath risk for 1 out of 4 residents in care.

Official plan of correction

Administrator Alvi Muhammad has agreed to have all staff attend a training regarding medication management by a CCL approved vendorized agency. Administrator will provide proof of completion by all staff by POC due date.

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

Official classification

Type B

Official code

87465(a)(e)(2)

Regulation authority

CCR

What the official deficiency says

Incidental Medical Care (a) A plan for incidental medical... shall be developed...in compliance with the following: (e)...written order from a physician, on a... the residents file, and a label...physician's order and the label shall contain....(2) The exact dosage. This requirement was not met as evidenced by: A facility records review revealed Resident1 did not have all health care orders regarding medication on file. This posed a potential heath risk for 1 out of 4 residents in care.

Official plan of correction

Administrator Alvi Muhammad has agreed to have all staff attend a training regarding record retention by a CCL approved vendorized agency regarding medication orders. Administrator will provide proof of completion by all staff by POC due date.

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

Official classification

Type B

Official code

87555

Regulation authority

CCR

What the official deficiency says

General Food Service Requirements: All food shall be...stored...in a safe and healthful manner (b) (27) All kitchen areas shall be..clean and free...vermin and insects. This requirement is not met as evidence by: Based on LPA observations, Licensee had an infestation at the facility. This posed a potential health risk to 2 out of 2 residents in care.

Official plan of correction

Licensee Alvi Muhammed immediately put a contract in place with a pest control agency and provided LPA with the service contract. Deficiency has been cleared.

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