ATRIA AT FOSTER SQUARE

Official classification

Type B

Official code

87465(i)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care This requirement is not met as evidenced by: Based on observation, interview and records review, the facility was not able to provide documentation to proof that the administrator was one of the participants for the Medication Destruction Process. Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the facility was not able to provide documentation to proof that the administrator was one of the participants for the Medication Destruction process. which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/18/2024 Plan of Correction The administrator will provide a plan in writing to ensure compliance with the Regulation. The administrator will provide a copy of the plan to CCL by 12/18/2024.

Official classification

Type A

Official code

87705(g)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia This requirement is not met as evidenced by: Based on observation and interview, LPA observed handsoap bottles for room 209B and 218B were not in their own possession as they were left unattended in the shared bathrooms. Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed handsoap bottles for room 209B and 218B were not in their own possession as they were left unattended in the shared bathrooms which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/11/2024 Plan of Correction The administrator/licensee will develop a plan in writing to ensure compliance and the plan shall indicate staff education. The administrator will submit a copy of the plan to CCL by 12/11/2024.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility.... This requirment is not met as evidenced by base on observation, interveiw and records review, R1's date of birth is incorrect on R1's facesheet which poses a potential health risk to residents in care.

Official plan of correction

The administrator/Licensee will develop a plan to ensure this does not happen again and will provide in-service to those who are involved with this process. The administrator will provide a copy of the plan and training records to CCL by 9/18/2024.

Deadline recorded: Sep 18, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(12)

Regulation authority

CCR

What the official deficiency says

87468.1Personal Rights of Residents in All Facilities..(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:..12) To wear their own clothes; to keep and use their own personal possessions, including their toilet articles;... This requirement is not met as evidenced by based on observation and interview, facility locked up R1's toothbrush and toothpaste which poses a potential health risk to resident in care.

Official plan of correction

The administrator/licensee will develop a plan to ensure residents have access to their own personal possessions at all time and will submit a copy of the plan to CCL by 5/7/2024. The plan shall include staff training.

Deadline recorded: May 7, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care- If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This regulation has not been met as evidenced by: Per the discovery made, med techs around June 2022 were not available due to COVID symptoms and illness on the day of their work shift so they could not go to work. It was identified that in that morning hours the residents in memory care did not receive medications.

Official plan of correction

Facility shall develop a plan of correction (POC) to ensure compliance with Sec.87465(c)(2). Licensee shall ensure in writing that all physicains order and prescritions are followed per the order or prescription. Medication training is to be provided. LPA is to receive plan via mail regarding.

Deadline recorded: Apr 5, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(9)

Regulation authority

CCR

What the official deficiency says

PERSONAL RIGHTS OF RESIDENTS....(a)Residents in all residential care facilities....(9) To have communications to the licensee from their representatives answered promptly and appropriately. This requirement was not met as evidenced by: the facility failed to provide R1's medical records as requested by the responsible party promptly and appropriately as requested which posed potential health and safety risks to resident in care.

Official plan of correction

The facility shall provide all the documents that are stated on the LIC809 to the responsible party and a copy to CCL by 4/5/2022. The administrator will review this regulation and submit a statement of acknowledgment after the review by the plan of correction due date 4/5/2022.

Deadline recorded: Apr 5, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87755(b)

Regulation authority

CCR

What the official deficiency says

87755 Inspection Authority of the Licensing Agency (b)The licensee shall ensure that provisions are made for private interviews with any resident or any staff member; and for the examination of all records relating to the operation of the facility. This requirement is not met as evidence by: During the couse of investigating the allegation, there was a caregiver identifed as S1 who was present with R1 right before R1 was transferred to the hospital but S1 was not coorporative with providing any inforamtion to assist with the investigation despite many attempts made by LPA including requesting the administrator to have S1 contact LPA which posed a potential health and safety risks to resident in care.

Official plan of correction

The administrator shall review the regulation and submit a signed statement of acknowledgment to CCL by the plan of correction due date of 4/12/2022. The administrator and/or the designee shall educate staff on this regulation and provide a copy of the education lesson plan and a copy of the sign-in sheet to CCL by the due date of 4/12/2022.

Deadline recorded: Apr 12, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87755(c)

Regulation authority

CCR

What the official deficiency says

87755 Inspection Authority of the Licensing Agency(c)The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. This requirment is not met as evidency by: The administrator has failed to provide the camera footage to the Department as requested which posed a potential health and safety risks to resident in care.

Official plan of correction

The administrator shall review the regulation and submit a signed statement of acknowledgement to CCL by the plan of correction due date of 4/12/2022.

Deadline recorded: Apr 12, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(d)(2)

Regulation authority

CCR

What the official deficiency says

87405 Administrator - Qualifications and Duties(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)..(2)Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by the administrator failed to provide the camera footage as requested by the Department and the administrator failed to ensure staff is corporative with investigation process which posed potential health and safety risks to resident in care.

Official plan of correction

The administrator shall review the regulation and submit a signed statement of acknowledgement to CCL by the plan of correction due date 4/12/2022.

Deadline recorded: Apr 12, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411a

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General(a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required.... the requirement is not met as evidence by: The facility failed to conduct a reappraisal prior to readmitting R1 from the hospital with health conditions and needs that were not previously required. Therefore, the facility failed to enure sufficient support staff were equipped to provide care to R1 which posed a potential health and safety risks to resident in care.

Official plan of correction

The administrator shall review the regulation and submit a statement of acknowledgement to CCL by the plan of correction due date 4/12/2022. The administrator shall educate facility staff and submit a copy of the lesson plan and a copy of the sign-in record to CCL by the plan of correction due to 4/12/2022.

Deadline recorded: Apr 12, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87224(a)(4)

Regulation authority

CCR

What the official deficiency says

87224 Eviction Procedures(a) The licensee may evict a resident..Thirty (30) days written notice to the resident is required..(4) If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted..This requirement was not met as evidenced by: On the day of R1's readmission to the facility from the hospital with health needs that were not previously identified. The administrator offered R1's responsible party to either hire a personal skill professional to care for the resident or to have R1 transfer back to the hospital. The facility failed to perform a reappraisal and issue a 30-day evict notice which posed immediate health and safety risks to resident in care.

Official plan of correction

The administrator will review the regulation and submit a signed written statement of acknowledgment to CCL by the plan of correction due date 4/1/2022. The administrator will educate facility on this regulation and provided a copy of the lesson plan and a copy of the facility staff sign-in record to CCL by the plan of correction due date 4/1/2022.

Deadline recorded: Apr 1, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(8)

Regulation authority

CCR

What the official deficiency says

87468.1Personal Rights of Residents in All Facilities (a)Residents in all residential care facilities..shall have.(8) To have their representatives regularly informed by the licensee of activities related to care...This requirement was not met as evidence by: When R1 was transferred to the hospital, the facility failed to contact the local responsible party listed in the contact list, and instead called one of the emergency contacts who lives in Florida, and who was unable to readily attend to R1’s emergency which posed potential health and safety risks to resident in care.

Official plan of correction

The administrator and/or the designee will review and verified all the resident's contact information to ensure accuracy and provide a statement to CCL after the verification of completion by the plan of correction due date 4/12/2022. The administrator and/or the designee will provide education to staff on the sequencing of calling resident's contacts based on the contact list and will provide a copy of the staff sign-in record to CCL by the due date 4/12/2022.

Deadline recorded: Apr 12, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(9)

Regulation authority

CCR

What the official deficiency says

PERSONAL RIGHTS OF RESIDENTS....(a)Residents in all residential care facilities....(9) To have communications to the licensee from their representatives answered promptly and appropriately. This requirement was not met as evidenced by: the facility failed to provide R1's medical records as requested by the responsible party promptly and appropriately as requested which posed potential health and safety risks to resident in care.

Official plan of correction

The facility shall provide all the documents that are stated on the LIC9099 to the responsible party and a copy to CCL by 3/22/22. The administrator will review this regulation and submit a statement of acknowledgment after the review by the plan of correction due date 3/22/2022.

Deadline recorded: Mar 22, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87611(e)

Regulation authority

CCR

What the official deficiency says

87611 GENERAL REQUIREMENT FOR ALLOWABLE HEALTH CONDITIONS..(e)In addition to Sections 87465(a).. the licensee shall ensure that the resident is cared for in accordance with the physician's orders..This requirement was not met as evidenced by: the facility failed to carry-out R1's Nurse Practitioner's order to provide supervision during meals due to a recent change in health condition which posed potential health and safety risks to resident in care.

Official plan of correction

The Administrator and/or designee will provide in-service to staff regarding this requirement and will provide a copy of the in-service lesson plan and staff sign-in sheet to the Regional Office by the due date 12/6/2021.

Deadline recorded: Dec 6, 2021. A deadline is not proof that correction was completed.