AVELLA AT ALMADEN

Official classification

Type A

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

87463(a)The 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,... This requirement is not met as evidenced by: Based on record review and interviews, R2’s appraisal dated 4/9/2025 which included the fall prevention was not updated after facility staff noted significant changes of R2 having documented 11 falls from 5/24/2025 to 6/20/2025 which poses/posed an immediate health, safety or personal rights risk to

Official plan of correction

Administrator stated to submit a written plan of action understanding regulation and will ensure appraisals are updated in writing which include signigficant changes in condition by POC due date. Administrator agreed and understood. (con't) persons in care.

Deadline recorded: Mar 11, 2026. 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 Incidental Medical and Dental Care (h)(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: This requirement is not met as evidenced by: Based on record review and interview, R1-R2's records of centrally stored medication were inaccurate which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

RSD stated the facility will conduct a mandatory in-service with all staff administering medications and plan of action is submitted by POC due date.

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

Official classification

Type B

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466 Observation of the Resident ...When changes such as unusual weight gains or losses ... are observed, the licensee shall ensure that such changes are documented... This requirement is not met as evidenced by: Based on record review, LPA did not observe weight log in residents' file in Assisted Living, RSD stated the staff do not observe resident's weight which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

RSD stated the facility will initiate weight log with new weight scale which accommadates residents with wheelchair and plan of action is submitted by POC due date.

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

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (e)(2) ...Hot water temperature controls shall be maintained ... the temperature of hot water used by residents to attain a temperature of not less than 105 degree F and not more than 120 degree F. This requirement is not met as evidenced by: Based on observation, LPA observed 9 out of 9 resident bathroom sinks with hot water temperatures ranging from 120.9F - 130.3F which poses/posed an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

RDH stated Maintenance Director will follow up with water temperatures in resident rooms to ensure it is within regulation and plan of action will be submitted by POC due date.

Deadline recorded: Jan 12, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (a)(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on interview and record review, IED and RSA stated the bedrooms and bathrooms were locked in the Memory Care Department and residents needs to ask staff to open the doors which poses/posed an immediate health, safety or personal rights risks to persons in care.

Official plan of correction

RDH stated the staff should not lock common bathroom and resident rooms and staff training will be provided and plan of action will be submitted by POC due date.

Deadline recorded: Jan 12, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (c)(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment... This requirement is not met as evidenced by: Based on record review of R2's file, R2 did not have an updated annual medical assessment which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

RSD stated R2's physician has been faxed in November 2023 and staff faxed the physician again today 1/11/2024. RSD will submit a plan of action by POC due date.

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

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

Additional Personal Rights of Residents in Privately Operated Facilities:(a)... residents...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...qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Licensee did not provide care and supervision to meet R1s needs wherein R1 was left unattended in front of the doctor's office which poses an immediate Health, Safety, or Personal Rights risk to persons in care.

Official plan of correction

Executive Director submit a written plan on understanding regulations and schedule in-services and training to staff by POC date. Executive Director agreed and understood.

Deadline recorded: Aug 23, 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

Criminal Record Clearance (e) All invididuals 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: (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 observation and record review, Facility failed to ensure 3 out of 3 staff members (S1-S3) associated to the facility which is an immediate safety risk to the residents in care. LPA observed S1-S3 are fingerprint cleared but not associated to the facility.

Official plan of correction

POC Due Date: 12/28/2022 Plan of Correction Assistant Executive Director correcred deficiency during today's visit. LPA was provided the Background Clearance letter assosciated with the facility for S1-S2. LPA observed Assistant Executive Director completing the LIC 9182 and faxing a copy to CCL for S3. *** A civil penalty of $1500.00 is being assessed.