WESTBOROUGH MANOR 6

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observations, LPA observed sharps to be unlocked and accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/23/2025 Plan of Correction Deficiency cleared and corrected. Sharps were immediately locked by caregiver.

Official classification

Type A

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 staff records reviewed, 5/5 staff were observed to not have the required training which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/23/2025 Plan of Correction Licensee/administrator shall develop a plan in writing on how to ensure staff complete annual training. The plan shall include conducting audits and ensuring all training is logged and maintained in each staff file.

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 record reviewed, facility did not have any documentation of the emergency drills being conducted quarterly which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/23/2025 Plan of Correction The licensee will develop a signed and dated plan to CCL by 8/23/2025 indicating when an emergency drill will be completed. The plan shall include ensuring that drills are conducted quarterly. The administrator will provide a copy of the emergency drill in-service sign in record to CCL by 8/26/2024.

Official classification

Type B

Official code

87555(b)(26)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, LPA did not observe 7 day non-perishables which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/29/2025 Plan of Correction Licensee/administrator will send LPA a photo of receipt and/or a photo of the non-perishables purchased.

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 resident records reviewed, the licensee did not comply with the section cited above as 5/5 residents did not have documentation of resident reappraisals which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/29/2025 Plan of Correction Licensee/administrator shall complete reappraisals for all 6 residents and provide LPA a plan on how to ensure reappraisals are being updated every 12 months or as needed.

Official classification

Type A

Official code

87207

Regulation authority

CCR

What the official deficiency says

87207 False Claims ..No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement is not met as evicenced by based on interviews, observation and record review, the administrator/licensee provided an insurance policy that was terminated in 2018-2019 and when it was active, it did not insure this facility which poses an immediate health risks to residents in care.

Official plan of correction

The administrator/licensee will develop a plan in writing and the plan shall indicate that the administrator/licensees has reviewed this regulation and what the administrator/licensees will do to prevent this from happening again. The administrator/licensees will provide a copy of the plan to CCL by 11/7/2024.

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

Official classification

Type A

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..(2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirment is not met as evidenced by based on observation, record review and interview, the administrator did not ensure the facility has an active General Liability Insurance Policy which poses an immediate health and safety risks to residents in care.

Official plan of correction

The administrator/Licensees will develop a plan in writing and the plan shall indicate that the administrator/licensees have reviewed the Regulation and the plan to ensure the facility is in compliance with the Regulations, and laws including but not limiting on obtaining a current General Liability Insurance for the facility. The administrator/Licensees will provide a copy of the plan to CCL by 11/7/2024.

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

Official classification

Type B

Official code

1569.605

Regulation authority

HSC

What the official deficiency says

1569.605 Liability insurance; coverage requirements... Based on interview, observation and record reveiw, This requirement is not met as evidenced by the facility did not provide a copy of the current liability insurance after several verbal and written reminders which poses a potential risk to residents in care.

Official plan of correction

The administrator/licensee will provide a copy of the current liability insurance to CCL by 10/25/2024.

Deadline recorded: Oct 25, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87211(a)(2)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: Facility did not report to CCL and Local Public Health when residents tested positive for COVID-19 Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 4 out 6 residents tested positive for COVID-19 and the facility did not reported to CCL and LPH which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/22/2024 Plan of Correction The Licensee will develop a signed and dated plan to CCL by 8/22/2024 to ensure the facility will be in compliance with Reporting Requirment and the plan shall indicate the date (no later than 8/28/2024) that the facility will complete the report requirement to CCL and LPH. After the reporting, the facility wil provide proof to CCL.

Official classification

Type B

Official code

87307(a)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: LPA observed staff living/rest area in the garage Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above LPA observed staff living/rest area in the garage as which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/27/2024 Plan of Correction The administrator will develop a plan to ensure the garage is not being used as a living/rest area for staff and in the plan, it shall indicate a comfortable location for staff to take breaks. The Licensee will provide proof/photos that the garage is no longer being used for staff and provide a copy of the plan and photos to CCL by 8/27/2024.

Official classification

Type A

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. 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 3 out of 3 staff did not have a current CPR and first aid training which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/22/2024 Plan of Correction The licensee will develop a signed and dated plan to CCL by 8/22/2024 indicating when the staff will be completing their CPR and first aid training (the date should be no later than 8/23/2024) and the plan shall indicate how is the facility going to prevent this from happening again.

Official classification

Type A

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 [(observation) (interview) (record review)], the licensee did not comply with the section cited above 3 out of 3 staff did not have any training from 2023 to present which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/22/2024 Plan of Correction The licensee will develop a signed and dated plan to CCL by 8/22/2024 indicating when the staff will be completing their training (the date should be no later than 8/27/2024) and the plan shall indicate how is the facility going to prevent this from happening again.

Official classification

Type A

Official code

87456(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal. 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 4 out of 6 resident did not have a copy of the pre-admission appraisal which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/22/2024 Plan of Correction The licensee will develop a signed and dated plan to CCL by 8/22/2024 indicating when the pre-admission appraisals will be completed for the 4 resident (the date should be no later than 8/27/2024) and the plan shall indicate how is the facility going to prevent this from happening again. The licensee will provide a copy of the pre-admission appraisals for all 4 residents to CCL by 8/27/2024.

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 facility did not have any documentation of the emergency drills which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/22/2024 Plan of Correction The licensee will develop a signed and dated plan to CCL by 8/22/2024 indicating when an emergency drill will be completed (the date shall be no later than 8/27/2024) and the plan shall indicate how is the facility going to prevent this from happening again. The administrator will provide a copy of the emergency drill in-service sign in record to CCL by 8/27/2024.

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 4 out of 6 residents have bedrails by the head of the bed without a physician's order which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/22/2024 Plan of Correction The licensee will develop a signed and dated plan to CCL by 8/22/2024 indicating when a physician's order will be obtained for the bed rails (the date should be no later than 8/27/2024). If the facility's assessment indicated the resident do not need the bed rails then the facility will provide a photo after the bed rail is removed. The plan shall indicate how is the facility going to prevent this from happening again. The licensee will provide a copy of the physician's order or the photo to CCL by 8/27/2024.

Official classification

Type B

Official code

87611(d)

Regulation authority

CCR

What the official deficiency says

(d) In addition to Section 87463, Reappraisals and Section 8, Observation of the Resident, the licensee shall monitor the ability of the resident to provide self care for the allowable health condition and document any change in that ability. 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 5 out of 6 residents did not a reappraisal which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/27/2024 Plan of Correction The licensee will develop a signed and dated plan to CCL by 8/27/2024 indicating how is the facility going to prevent this from happening again and will provide a copy of the resident's reappraisal to CCL by 8/27/2024.

Official classification

Type A

Official code

87205(a)(b)

Regulation authority

CCR

What the official deficiency says

87205 Accountability of Licensee Governing Body..a) The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility..(b) If the licensee is a corporation or an association, the governing body shall be active, and functioning in order to assure accountability.. This requirement is not met as evidenced by based on the audit result, the licensee failed to pay rent, utility bills on time and licensee's corporation status with Secretary of State is Franchise Tas Board (FTB) suspended which poses an immediately risk for residents in care.

Official plan of correction

Licensee and administrator will develop a plan to ensure facility operation expenses including but not limiting to utility bills and rent are paid on time. Licensee will submit a copy of the plan to CCL by 9/13/2023. In addition, Licensee is to furnish proof that obligations owed to FTB have been cleared and that corporate status has been reinstated. If licensee is operating under a different corporation, a new license application must be submitted. Furthermore, facility will comply with Audit Section quarterly Financial Monitoring for a period of one year and provide requested documents.

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

Official classification

Type A

Official code

87555(a)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements..a)The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council.. This requirement is not met as evidenced by based on the audit result, the facility failed to supplied food to resident to meet the nutritional guidelines which poses an immediately health risk to residents in care.

Official plan of correction

The licensee and administrator will develop a plan to ensure facility is supplying food to all the residents in care according to the recommended dietary allowances. Licensee will submit a copy of the plan to CCL by 9/13/2023. In addition, the facility will comply with Audit Section quarterly Financial Monitoring for a period of one year and provide monthly food receipts.

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

Official classification

Type A

Official code

87213

Regulation authority

CCR

What the official deficiency says

87213 Finances..The licensee shall have a financial plan that conforms to the requirements of Section 87155, Application for License, and that assures sufficient resources to meet operating costs for care of residents; This requirement is not met as evidenced by based on the audit result, licensee is not making sufficient income to meet operating expenses which poses an immediately health risk to residents in care.

Official plan of correction

The licensee will review facility financial status and make adjustments to ensure operating expenses are met. After the review, the licensee will develop a plan to ensure facility income is sufficient to cover all the operating expenses. A copy of such plan will be submitted to CCL by 9/13/2023. In addition, the facility will comply with Audit Section quarterly Financial Monitoring for a period of one year and provide requested documents.

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

Official classification

Type A

Official code

87405(d)(1)(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). If the licensee is also the administrator, all requirements for an administrator shall apply..(1) Knowledge of the requirements for providing care and supervision.. (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 ensure residents are adequately fed and bills are paid in a timely manner which poses an immediately health risk to residents in care.

Official plan of correction

The licensee and administrator will review the regulation and provide a copy of a signed statement acknowledging the review. The administrator will provide a plan on how he/she will monitor to ensure residents are receiving food according to the Recommended Dietary Allowances, facility rent, and ancillary bills are paid in a timely fashion. The plan and the statement will be submitted to CCL by 9/13/2023. In addition, the facility will comply with Audit Section quarterly Financial Monitoring for a period of one year and provide request documents

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

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above- during the facility tour that was provided by the administrator, LPA observed chemical and toxins are stored in a closet, however, door was not locked as there was a blue tape covering the lock that prevented the door from locking which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/15/2023 Plan of Correction The administrator removed the tape and the door was locked. The administrator will provided in-services to staff on the importance of locking the chemical/toxins storage closet door at all times. In addition, the administrator will develop a plan to ensure compliance. The administrator will provide a copy of the plan and a copy of the staff in-service sign-in record to CCL by 2/15/2023.

Official classification

Type B

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview the licensee did not comply with the section cited above in as LPA did not observe any COVID-19/Infection control postings by the front entrance and in the facility which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/21/2023 Plan of Correction The administrator will post the signs by the front entrance, in the bathrooms and within the facility. The administrator will send pictures of the postings by 2/21/2023.