BURLINGAME SENIOR HOME

Official classification

Type A

Official code

87412(a)(11)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as S2 did not have a completed health screen which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/01/2026 Plan of Correction The administrator will submit a plan to ensure S2 completes a health screen and will provide a copy of the health screen to CCL by 7/1/2026. The administrator stated that she will send S2 to complete the health screen by 7/1/2026.

Official classification

Type A

Official code

87355(e)(3)

Regulation authority

CCR

What the official deficiency says

(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: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/01/2026 Plan of Correction The administrator stated that she will submit the LIC 9182 and a copy of S2's ID to CCL to complete the criminal transfer process by 7/1/2026. The administrator will submit a plan of correction to ensure the facility is active on Guardian to complete the criminal background process moving forward. The administrator will provide a copy of the plan to CCL by 7/1/2026.

Official classification

Type B

Official code

87355(j)

Regulation authority

CCR

What the official deficiency says

(j) The licensee shall maintain documentation of criminal record clearances or criminal record exemptions of employees in the individual's personnel file as required in Section 87412, Personnel Records. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as S1 and S2 did not have a copy of their criminal record clearance in their personnel file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/08/2026 Plan of Correction The administrator will develop a plan indicating that she will print a copy of documents and place it in their files.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed R1, R3 and R4 did not have an updated reappraisal which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/14/2026 Plan of Correction The administrator will submit a plan of correction to ensure reappraisals are completed accordingly and a copy of the completed reappraisals for R1, R3 and R4 to CCL by 7/14/2026.

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed R2 has a half rail by the bed without a physician's order which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/14/2026 Plan of Correction The administrator will submit a plan of correction to ensure there is a physician's order for postural support devices that are being utilize on residents and a copy of the plan and a copy of the physician's order for R2 CCL by 7/14/2026.

Official classification

Type A

Official code

87405(d)(1)(2)

Regulation authority

CCR

What the official deficiency says

87405 Administrator - Qualifications and Duties This requirement is not met as evidenced by: based on observation, record reviews and interviews, the facility has received multiple repeat deficiencies. Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above based on observation, record reviews and interviews, the facility has received multiple repeat deficiencies which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/01/2026 Plan of Correction The Administrator will review all the repeat deficienies that were obtained from 2024, 2025 and 2026 and develop a plan of correction for each repeat deficiency to ensure compliance and will submit a copy of the plan to CCL by 7/1/2026.

Official classification

Type A

Official code

87355(e)(3)

Regulation authority

CCR

What the official deficiency says

(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: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed S1 and S2 did not complete the transfer criminal record clearance which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/06/2025 Plan of Correction The administrator/licensee will develop a plan to ensure compliance and complete the criminal record clearance process for both staff members by 6/6/2025. The administrator/licensee will provide a plan of correction to CCL by 6/6/2025.

Official classification

Type A

Official code

87458(c)(1)(A)

Regulation authority

CCR

What the official deficiency says

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed resident #4 (R4)'s TB a status for Tuberculosis was blank on the Medical Assessment and the administrator/licensee was not able to provide documentation that it was completed which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/06/2025 Plan of Correction The administrator/Licensee will develop a plan to ensure compliance and the plan shall indicate the date that this will be completed and provide a copy of the plan to CCL by 6/6/2025.

Official classification

Type A

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the administrator was not able to provide documentation to proof that emergency drills were conducted after Jan 2024 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/06/2025 Plan of Correction The administrator/licensee will develop a plan to ensure emergency drills are completed accordingly and will provide a copy of the plan to CCL by 6/6/2025.

Official classification

Type A

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as resident #1 (R1) has bed rails and the facility was not able to provide a written order by the physician which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/06/2025 Plan of Correction The administrator/licensee will develop a plan to ensure compliance and the plan shall indicate when a written order will be obtained and submit the plan to CCL by 6/6/2025.

Official classification

Type A

Official code

87618(b)(3)(B)

Regulation authority

CCR

What the official deficiency says

(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed R1 and R4 are on oxygen and LPA did not observed any " No Smoking - Oxygen " posted which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/06/2025 Plan of Correction The administrator/licensee will develop a plan to ensure compliance and will provide a copy of the plan and photo of the sign(s) to CCL by 6/6/2025.

Official classification

Type B

Official code

87412(g)

Regulation authority

CCR

What the official deficiency says

(g) All personnel records shall be maintained at the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed S2's personnel file was not maintained at the facility and the administrator/licensee stated that it was at the sister facility which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/12/2025 Plan of Correction The administrator/licensee will develop a plan to ensure compliance and will provide a copy of the plan to CCL by 6/12/2025.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed R2 did not have a current reappraisal which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/12/2025 Plan of Correction The administrator/licensee will develop a plan to ensure compliance and will provide a copy of the plan to CCL by 6/12/2025.

Official classification

Type B

Official code

87618(b)(3)(A)

Regulation authority

CCR

What the official deficiency says

(3) Ensuring that the use of oxygen equipment meets the following requirements: (A) A report shall be made in writing to the local fire jurisdiction that oxygen is in use at the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed R1 and R4 are on Oxygen and the facility was not able to provide proof that the local fire jurisdiction was notified which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/12/2025 Plan of Correction The administrator/Licensee will develop a plan to ensure compliance and the plan shall indicate the date that this will be completed and provide a copy of the plan and a copy of the written notification to CCL by 6/12/2025.

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: 87608 Postural Supports Deficient Practice Statement Based on observation, interview and record review the licensee did not comply with the section cited above as 3 out of 5 resident has half bedrails without a physician's order which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/22/2024 Plan of Correction The administrator/licensee will develop a plan to ensure there is a physician's order for half bedrails for all the residents. The administrator/licensee will provide a copy of the physician's order for the current 3 residents who has half bedrail. The administrator/licensee will provide a copy of the plan and the physician's order to CCL by 5/22/2024.

Official classification

Type A

Official code

87608(a)(1)

Regulation authority

CCR

What the official deficiency says

87608- Postural Support..(a) Based on the individual's preadmission appraisal,..(1) Postural supports shall be.. to improve a resident's mobility and independent functioning..but not limited to, preventing a resident from falling out of bed, a chair, etc. This requirement is not met as evidenced by the facilty places devices next to resident #1's bed without a phsyician's order and staff reported the intent was to prevent resident #1 from falling out of bed which posed an immediate health risk to residents in care.

Official plan of correction

The facility will reassess the devices that are currently being used and will obtain a physician's order for the devices that will be continued to use after the assessement, and provide documentation. The facility will remove the device(s) immediately that is not prescribed by the physician, The administrator will review this regulation and provide a copy of a signed acknowledgement statement after the review. In addition, the administrator will provide in-services to staff and provide a copy of the sign-in sheet by 8/4/22.

Deadline recorded: Aug 4, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

87608 Postural Supports..(a) Based on the individual's preadmission appraisal,.(3)A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record This requirement is not met as evidenced by the facility did not obtain a written order from the physician for resident #1's quarter bed rails which poses a potential health risk to residents in care.

Official plan of correction

The administrator will provide in-services to staff and provide a copy of the sign-in sheet to CCL by the plan of correction due date 8/15/2022.

Deadline recorded: Aug 15, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(a)

Regulation authority

CCR

What the official deficiency says

87307 Personal Accommodations and Services..(a)Living accommodations and grounds..The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, .... This requirement is not met as evidence by Staff #2 reported sleeping in the resident's living room at night which poses a potential health risk to residents in care.

Official plan of correction

The administrator will rearrange a sleeping accommodation for staff #2. Administrator will review the regulation, provide an in-service to staff and provide a copy of the in-service sign-in record to CCL by the plan of correction due date 8/15/2022.

Deadline recorded: Aug 15, 2022. A deadline is not proof that correction was completed.