CAMPBELL VILLAGE

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

87463 Reappraisals (a) The pre-admission appraisal… shall be updated in writing as frequently as necessary …to note significant changes in condition…and to keep the appraisal accurate… This requirement was not met as evidence by: Based on records reviewed and interviews conducted, the changes facility ADM stated she implemented to address R1’s falls were not reflected on R1’s Needs and Services Plan. ADM acknowledged she did not update the care plan. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

ADM stated she will send a letter of understanding regarding the regulation. ADM stated she will send the plan of correction to LPA by POC date, March 26, 2025

Deadline recorded: Mar 26, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87457(c)

Regulation authority

CCR

What the official deficiency says

87457 Pre-Admission Appraisal (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed ... their individual service needs ... specified in Section 87455, Acceptance and Retention Limitations. This requirement was not met as evidenced by: Based on record review, the residents pre admission appraisal was not filled out and had missing information such as Residents Name & Age, Health, physical disabilities, mental condition, health history & social factors. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

ADM stated she will send a letter of understanding regarding the regulation. ADM stated she will send the plan of correction to LPA by POC date, February 20, 2025.

Deadline recorded: Feb 20, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. 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. While touring Memory Care, LPAs tested delayed egress door #4 (next to resident rooms #124 and #125). LPAs pushed the door completely open, and the delayed egress did not sound the alarm which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/11/2024 Plan of Correction Staff member activated the delayed egress with a key and the door alarm was activated during visit. ADM stated she will conduct an in-service training with staff regarding delayed egress policy and submit documentation of in-service training by POC due date. ADM will also submit a letter of understanding of the regulation cited and submit to LPA by POC due date.

Official classification

Type A

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. While touring resident bedroom 111, LPAs observed a plastic tube obstructing the sliding glass door, preventing the door from opening which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/11/2024 Plan of Correction ADM removed plastic tube from the sliding glass door during visit. ADM will submit a letter of understanding of the regulation cited and submit to LPA by POC due date.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Licensee did not ensure that resident R1 did not elope from the facility unassisted, which poses an immediate safety risk to residents in care.

Official plan of correction

Licensee agrees to submit a Plan of Correction to CCL by POC date stating how the facility staff will receive in-service training on preventing Memory Care residents from leaving the facility unassisted. Once training is complete, the Licensee agrees to submit training records including names of staff trained, training dates, training topics, and name(s) and qualifications of trainer(s) to CCL.

Deadline recorded: Aug 15, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (a)(1)(D) Any incident which threatens the welfare, safety or health of any resident... or other residents, or unexplained absence of any resident. This requirement was not met as evidenced by; Based on interview & record review, the facility did not send an incident report regarding R1's falls on February 7, 2024, March 2 and 7, 2024, and May 13, 2024. Staff S1 stated he/she didn't send an incident report for these falls. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

ADM stated she will send a letter of understanding regarding the Regulation. ADM stated she will send the letter by POC date, June 13, 2024.

Deadline recorded: Jun 13, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

80088(e)(1)

Regulation authority

CCR

What the official deficiency says

80088(e)(1) Furniture, Fixtures, Equipment, and Supplies - (e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as the water temperature was measured to beneath 105 *F in 3 out of 3 tested bathrooms which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/24/2022 Plan of Correction Facility is currently in the process of brining in maintanance worker to inspect water heater. Facility to submit daily temperature log and schedule a plumber to fix the water heater by POC due date.