WILLOW OAKS SENIOR LIVING

Official classification

Type B

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. Licensee did not store resident's medication in its original container and staff were using pill boxs to store resident's medications to administer two days in advanced. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/23/2026 Plan of Correction ADM stated she will send a written plan of action on how she will ensure Each resident's medication shall be stored in its originally received container and No medications shall be transferred between containers. ADM stated her plan of action will explain how medications will be administered the days she has off. ADM stated she will send Plan of action to the Department by POC due date.

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 and to keep the appraisal accurate... This requirement was not met as evidenced by: Based on a review of R1’s LIC625, R1 has a rummaging, wandering behavior & incontinence wherein R1 smears his/her feces on bathroom walls and self. R1’s behavior has not been addressed other than locking R1’s bathroom. The facility locking the bathroom door was not written on the plan of care.

Official plan of correction

ADM stated he/she will send letter of understanding regarding the regulation to LPA by POC date, 11/27/2023.

Deadline recorded: Nov 27, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

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; R1’s lack of supervision and absence of care plan to address R1’s behavior leads to feces smearing, which is unsanitary for R1 and R5. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

ADM stated they will send a letter of understanding regarding the regulation to LPA by POC date, 11/23/2023.

Deadline recorded: Nov 23, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

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)(4) To care, supervision, ... 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; Based on interview with ADM & LN; R1's shared bathroom was locked due to R1's behaviors. ADM & LN stated R1 had multiple instances of smearing when he/she was left unsupervised in bedroom #1's bathroom. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

ADM stated they will send a letter of understanding regarding the regulation to LPA by POC date, 11/23/2023.

Deadline recorded: Nov 23, 2023. A deadline is not proof that correction was completed.