COLLEGE MANOR

Official classification

Type A

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

POSTURAL SUPPORTS Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement was not met, as there are 2 full bed rails used for clients #3 and #4, which poses an immediate health, safety or personal rights risk to clients in care. Licensee failed to prohibit the use of full bed rails.

Official plan of correction

Full bed rails for clients #3 and #4 were shortened to half bed rails in LPA's presence. Deficiency corrected and cleared

Deadline recorded: May 21, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(6)

Regulation authority

CCR

What the official deficiency says

INCIDENTAL MEDICAL CARE (h)(6) A record of centrally stored Rx medications for each resident shall be maintained and include names of the resident for whom prescribed, prescribing physician and pharmacist, drug name, strength and quantity, dates filled, started & expiration, prescription number and instructions. This requirement is not met, as medications for client #2 are not recorded on Centrally Stored Medications Record, which poses an immediate health, safety or personal rights risk to clients in care. Licensee failed to ensure that all client medications are logged in CSMR.

Official plan of correction

All medications will be recorded on Centrally Stored Medications Records, including for client #2. Proof of correction will be sent to CCLD BY DUE DATE.

Deadline recorded: May 22, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

POSTURAL SUPPORTS A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. This requirement was not met, as there are no MD orders on file for half bed rails for clients #1, #2, #3, #4. Licensee failed to maintain MD orders for half bed rails, which poses a potential health, safety or personal rights risk to clients in care.

Official plan of correction

Written MD orders for half bed rails for clients #1, #2, #3, #4 will be sent to CCLD BY DUE DATE

Deadline recorded: Jun 4, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(26)

Regulation authority

CCR

What the official deficiency says

GENERAL FOOD SERVICE Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirment is not met, as there is not eough canned fruit and vegetables for 7 day supply. Licensee failed to maintain 7-day supply of canned fruits and vegetables, which poses a potetial health, safety or personal rights risk to clients in care.

Official plan of correction

Seven day supply of canned fruits and vegetables will be maintained. Proof of correction to be sent to CCLD BY DUE DATE.

Deadline recorded: Jun 4, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). 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 by having the hot water temperature at 140 degree F which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/09/2023 Plan of Correction Licensee adjusted the water temperature during visit. Licensee will take a picture of the hot water temperature and send the picture to LPA by POC due date.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and record review the licensee did not provide facility staff with annual training in 2023 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/09/2023 Plan of Correction Licensee will provide staff training annually. Licensee will submit a statement of understanding of the section cited above to LPA by POC due date.

Official classification

Type B

Official code

87463(c)

Regulation authority

CCR

What the official deficiency says

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and record review the residents appraisal needs and services plans were updated more than 12 months ago which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/09/2023 Plan of Correction Licensee will submit a statement of understanding that all appraisal needs and services plans will be updated yearly to LPA by POC due date.

Official classification

Type A

Official code

87355(e)(1)

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: (1) Obtain a California clearance or a criminal record exemption as required by the Department or ... This requirement was not met as evidenced by: Based on record review, interview, and observation the Licensee did not comply with the section cited above for staff (S1) working and residing in the facility without fingerprint clearance which poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

Staff (S1) was asked to leave the facility. Licensee was informed S1 cannot reside or work in the facility until a fingerprint clearance has been obtained. Licensee will submit a written plan to LPA by POC due date.

Deadline recorded: May 25, 2023. A deadline is not proof that correction was completed.