Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 1569.625(b)(2)
- Regulation authority
- HSC
What the official deficiency says
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review and manager interview, Licensee did not ensure that 2 of 5 sampled staff (S1 and S2) had completed 20 hours of training within the last year, of which 8 hours were required to be on dementia care and of which 4 hours were required to be on postural supports, restricted health conditions, and hospice care. This posed a potential health and personal rights risk to 31 of 31 residents [R1 through Resident #31 (31)] in care.
Official plan of correction
POC Due Date: 01/11/2026 Plan of Correction Licensee agreed to have S1 and S2 each finish 20 hours of annual training (ensuring at least 8 hours are on dementia care and at least 4 hours are on " postural supports, restricted health conditions, and hospice care " ). Licensee agreed to clearly document the training, and to send proof of completion to LPA, by the POC due date.
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87463(h)(1)
- Regulation authority
- CCR
What the official deficiency says
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. (1) Documentation of the annual routine visit, such as a visit summary, shall be added to the resident's record. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review and manager interview, Licensee did not ensure that 2 of 5 sampled residents (R1 and R2) had documentation of an annual routine visit with a licensed medical professional. This posed a potential health risk to persons in care.
Official plan of correction
POC Due Date: 01/11/2026 Plan of Correction Licensee agreed to coordinate with the responsible persons (RP) to ensure that R1 and R2 complete their annual routine physicals/medical visits. (In cases where the RP refuses the annual visit, Licensee will document such refusal in writing.) Licensee agreed to send proof of completion to LPA, by the POC due date.
Resident rightsType B
- Official classification
- Type B
- Official code
- 87467(a)(3)
- Regulation authority
- CCR
What the official deficiency says
(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 the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals. This requirement is not met as evidenced by: Deficient Practice Statement Based on records review and manager interview, for 4 of 5 sampled residents (R1 through R4), Licensee did not within the last 12 months arrange a meeting with the resident and required individuals to review and revise the written record of care. This posed a potential health risk to persons in care.
Official plan of correction
POC Due Date: 01/11/2026 Plan of Correction For R1 through R4 each, Licensee agreed to conduct a care conference with their responsible person (and home health/hospice personnel, as applicable) to review the resident's facility Plan of Care, updating it as needed. All parties to the meeting will sign. Licensee agreed to E-mail proof of care conference completion to LPA, by the POC due date. Going forward, Licensee agreed to faciliate such care conferences at least once every 12 months for each resident.
Health conditions and treatmentsType B
- Official classification
- Type B
- Official code
- 87633(b)(6)(B)
- Regulation authority
- CCR
What the official deficiency says
87633 Hospice Care of Terminally Ill Residents: “(b)(6)(B) The hospice agency will provide training specific to the current and ongoing needs of the individual resident receiving hospice care and that training must be completed before hospice care to the resident begins.” This requirement is not met as evidenced by: Deficient Practice Statement Based on records review and manager interview, Licensee did not ensure that the hospice agency trained 15 of 15 facility staff (S1 through Staff #15) on 1 of 1 hospice residents' (R5's) current and ongoing individual care needs. This posed a potential health risk to persons in care.
Official plan of correction
POC Due Date: 01/11/2026 Plan of Correction Licensee agreed to coordinate with the hospice agency for one of their nurses to lead an in-service training for staff, covering both the hospice care plan and the current and ongoing care needs of R5. Licensee agreed to E-mail the training sign-in sheet(s) to LPA, by the POC due date.