MARY FRANCES HAT RESIDENTIAL FACILITY

Official classification

Type A

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 record review, the licensee did not comply with the section cited above in [1] out of [5] facility staff records did not possess proof of cleared TB which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/24/2026 Plan of Correction The facility designated Administrator stated that all facility staff records will be audited to make sure that all of them are properly cleared and documented for TB clearance. A statement of correction, along with an updated medical assessment verifying TB clearance, will be completed and submitted into CCL by the due date for review by this LPA.

Official classification

Type A

Official code

87615(a)(1)

Regulation authority

CCR

What the official deficiency says

Prohibited Health Conditions -Persons who require health services for or have a health condition including but not limited to, those specified below, shall not be admitted or retained in a residential care facility for the elderly: Stage 3 and 4 pressure injuries. This requirement is not met as evidence by: Based on LPA Campbell’s observation of file reviews for R1 and Adventist Home Health Nurse’s statement that R1 had a Stage Three Pressure Wound while in the facility for more than 24 hrs. This poses an immediate risk to the health, safety and personal rights of residents in care.

Official plan of correction

POC The licensee shall train all staff on prohibited health conditions and submit a signed attendance roster of all employees that were educated on the regulation along with a statement of understanding to LPA by POC due date of 10/13/2023.

Deadline recorded: Oct 13, 2023. A deadline is not proof that correction was completed.