EXCELSIOR HEALTHCARE CENTER

Official classification

Type A

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This facility was found to be deficient as evidenced by this facility designated Administrator not being aware of a relationship developing between a facility resident and staff person which resulted in a marriage and eventual move out which posed an immediate threat to the Health, Safety, and Personal Rights to the residents in care.

Official plan of correction

The facility designated Administrator stated that he/she will undergo training, for no less than one hour in duration, on the subject matter of facility residents rights and how to properly maintain them at all times. A statement of correction, along with copies of the updated training, will be completed and submitted into CCL by the due date. Proof of completed training will involve the topic of training, name of the vendorized trainer, and list of attendee(s).

Deadline recorded: Mar 9, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(c)(3)(E)

Regulation authority

CCR

What the official deficiency says

All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 The training shall include, but not be limited to, the following: Psychosocial needs of the elderly, such as recreation, companionship, independence, etc. This facility was found to be deficient as evidenced by the allowance of a facility staff person engaging in a relationship with a facility resident requiring care and supervision which posed an immediate threat to the Health, Safety, and Personal Rights of all residents in care.

Official plan of correction

The facility designated Administrator stated that all facility staff will undergo training, for no less than one hour in duration, on the subject matter of facility residents rights and how to properly maintain them at all times. A statement of correction, along with copies of the updated training, will be completed and submitted into CCL by the due date. Proof of completed training will involve the topic of training, name of the vendorized trainer, and list of attendee(s).

Deadline recorded: Mar 9, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87305(a)

Regulation authority

CCR

What the official deficiency says

87305 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement was not met as evidence by; Based on tour and floor plan review, staff bedroom across dining room converted to a resident and staff bedroom , bedroom #3 and the master bedroom has partition walls inside each of them without blding permits/fire clearance. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

ADM stated she will send LPA a written plan of action the existing partitions with no building permits/fire clearance. ADM will submit POC on or before February 3, 2025.

Deadline recorded: Feb 3, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(g)

Regulation authority

CCR

What the official deficiency says

87412 Personnel Records (g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review. This Requirement was not met as evidenced by Based on record review, ADM stated she did not have staff records for her on-call Administrator. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

ADM stated she will send a written letter of understanding regarding about ensuring personnel records are available at the facility. ADM stated she will send to LPA by POC date, February 3, 2025.

Deadline recorded: Feb 3, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (c) (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement was not met as evidenced by; Based on record review and interview, S2's first aid training/cpr trainining expired 6/2024. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

ADM stated ADM will schedule S2 to obtain first aid/CPR training. S2 is allowed to work but with another staff who has a valid first aid/CPR on duty. ADM will submit evidence of S1's training on or before POC date. ADM stated she will send documentation showing, Staff S2 had completed his/her first aid training. ADM stated she will send the plan of correction by POC date, February 3, 2025.

Deadline recorded: Feb 3, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (f) All personnel, including the licensee and administrator, shall be in good health... verified by a health screening...signed by the examining physician.... This requirement was not met as evidenced by; Based on interview and record review, Staff S2 does not completed heath screening signed by his/her physician though there is a TB/x-ray done. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

ADM stated she will have staff S2 complete a health screening. S2 stated she will send LPA a copy of a completed health screening. ADM stated she will also send a letter of understanding regarding the regulation. ADM stated she will send the plan of correction to have S2 obtain health screening LPA by POC date, February 3, 2025.

Deadline recorded: Feb 3, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(d)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records (d) All resident records shall be available to the licensing agency to inspect, audit, ... during normal business hours.... This requirement was not met as evidenced by; Based on interview conducted, ADM stated she could not find R1's file. ADM stated she looked for it but could not provide to LPA to inspect/ Audit. This pose/poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

ADM stated she will send a written letter of understanding regarding the regulation and the importance of having residents records avalable to inspect/ audit. ADM stated she wil send the plan of correction by POC date, November 25, 2024.

Deadline recorded: Nov 25, 2024. 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

87303 Maintenance and Operation (a) 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 the licensee did not comply with the section cited above by not maintaining a clean, safe, sanitary and in good repair and condition the toilet seat rail/grab bar which pose/poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/15/2024 Plan of Correction Administrator stated that the toilet seat rail/grab bar will be replaced by the end of the day and will send proof of correction by the POC due date.

Official classification

Type B

Official code

87455(b)(7)

Regulation authority

CCR

What the official deficiency says

87455 Acceptance and Retention Limitations (b) The following persons may be accepted or retained in the facility: (7) Persons who are under 60 years of age whose needs are compatible with other residents in care, if they require the same amount of care and supervision as do the other residents in the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above, R3 and R4 are both under the age of 60. The facility has a census of 5 and capacity of 6. ADM did not send exception request prior to admitting the R3, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/29/2024 Plan of Correction ADM stated that an exception request will be submitted to LPA with the required information that states the compatibility of R3 with other residents in care.

Official classification

Type A

Official code

87461(a)(5)

Regulation authority

CCR

What the official deficiency says

87461 Mental Condition (a) The facility shall determine the amount of supervision necessary by assessing the mental status of the prospective resident to determine if the individual(5) has a documented history of behaviors which may result in harm to self or others. This requirement is not met as evidenced by: Based on documentations and records reviewed, there is no mental/medical health assessment to address R1’s condition.

Official plan of correction

Licensee/administrator stated the plan of correction (POC) will be submitted on the due date. LIcensee stated he/she will re-train staff regarding documentation and reporting to administrator not just verbally but also in writing. Administrator will create procedure for staff to monitor residents.

Deadline recorded: Feb 24, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87405(d)(1)

Regulation authority

CCR

What the official deficiency says

87405 Administrator - Qualifications and Duties(d) The administrator shall have the qualifications specified...Sections 87405(d)(1) to (7). If the licensee...all requirements for an administrator... (1) Knowledge of the requirements for providing care and supervision appropriate to the residents. This requirement is not met as evidenced by: Based on the records reviewed and interviews, ADM and staff did not address R1’s mental health condition when R1 was observed by staff ‘looked like R1 had a low energy and less appetite and hard time urinating” prior to the incident.

Official plan of correction

Licensee/administrator stated the plan of correction (POC) will be submitted on the due date. LIcensee stated he/she will have the resident re-evaluated by Evaluation Psychiatric Services (EPS). Licensee stated that any change in condition will be reported to the PCP and keep a record of the changes.

Deadline recorded: Feb 24, 2024. A deadline is not proof that correction was completed.