SANTA MARIA TERRACE

Official classification

Type B

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (a) (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met based on interviews and records reviewed, licensee did not comply with the section cited above when Staff gave R1 a medication at 9:55am, but order and interview with medical professional stated “bedtime”, which posed a potential health and safety risk to the resident in care.

Official plan of correction

Facility will complete an in-service training with medication staff regarding PRN awareness of possible time frame parameters, and an audit of the electronic Medication Administration Records (eMAR) will be reviewed to ensure the eMAR matches the Orders.

Deadline recorded: Sep 5, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility... (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on interviews, the licensee did not comply in the section sited above when staff did not properly assist residents with medications and issued the incorrect dose which posed an immediate health and safety risk to residents in care.

Official plan of correction

From 1/24/23-1/26/24 Facility conducted an in service training for all med techs on the importance of live passing medications and Wellness Director met with each med tech individually for a knowledge check on live pass. POC was completed at the time of the visit.

Deadline recorded: Feb 2, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(4)

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: (4) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility. 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 two staff were not associated to the facility, which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 09/06/2023 Plan of Correction Administrator immediately re-associated staff. Administrator stated they think a staff accidentally disassociated the two staff. The POC was cleared during the visit.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed...(4) The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidenced by: Based on record review, the licensee did not comply with the section cited above when the facility did not follow doctors orders and properly assist resident with medication, which poses an immediate health and safety risk to persons in care.

Official plan of correction

Facility immediately took the medtech responsible off medication passes and retrained medtechs on the 7 steps of issuing mediation. Plan of correction complete.

Deadline recorded: Jun 15, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(h)(6)

Regulation authority

CCR

What the official deficiency says

87465(h)(6) Incidental Medical and Dental Care (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: (C) The drug name, strength and quantity. This requirment was met as evidenced by: Based on record review, the licensee did not comply with the section cited above when the facility did not assure the centrally stored medications had the correct quantity, which poses a potential health and safety risk to persons in care.

Official plan of correction

Administrator agreed to train medtech's on the proper way to fill out the centrally stored medication log and submit training to CCL with name, date, and topic covered by 6/22/23.

Deadline recorded: Jun 22, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

87211(a)(1)(D) Reporting Requirements (a) Each licensee shall furnish... the following: (1)A written report shall be submitted to the licensing agency...within seven days of the occurrence of any of the events specified in (A) through (D) below.... This requirment was not met as evidenced by: Based on record review, the licensee did not comply with the section cited above when the facility did not submit a written report within 7 days, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator agreed to submit a plan to ensure written reports will be submitted to CCL within 7 days and submit plan to LPA by 1/26/23.

Deadline recorded: Jan 26, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(2)

Regulation authority

CCR

What the official deficiency says

87211(a)(2) Reporting Requirements (a) Each licensee shall furnish....reports ...(2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents...within 24 hours either by telephone or fax... This requirment was not met as evidenced by: Based on record review, the licensee did not comply with the section cited above when the facility did not report an epidemic outbreak within 24 hours, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator agreed to submit a plan to ensure occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents will be reported to CCL within 24 hours and submit plan to LPA by 1/26/23

Deadline recorded: Jan 26, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

87355(e)(1) Criminal Record Clearance. (e) All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or criminal record exemption... or (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) 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 2 out of 40 staff were not associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/01/2022 Plan of Correction Adminsitrator agreed to associate both staff by 09/01/2022

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

87211(a)(1) Reporting Requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below... This requirement was not met as evidenced by: Based on record review, the licensee did not ensure incident reports were sent within 7 days of the occurrence on multiple occasions, which posed a potential health, safety, and personal rights risk to residents in care.

Official plan of correction

The Administrator agreed to do the following: Review Regulation 87211 and submit a Statement of Understanding, detailing how the licensee plans to maintain voluntary compliance. Submit statement no later than 7/15/22.

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

Official classification

Type A

Official code

87411(g)(1)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: LPA reviewed Guardian and LIS roster and discovered individual has an inactive status. Fingerprints Deficient Practice Statement Based on record review and observation of the individual being present at the facility, the licensee did not comply with the section cited above in 1 count, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/01/2021 Plan of Correction Facility will remove individual from the roster while the individual completes LIC 9163 Request for Live Scan Services.