HEATHERFIELD INN

Official classification

Type B

Official code

87412(c)

Regulation authority

CCR

What the official deficiency says

(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in that 2 Out of 2 staff records were observed without the staff training records maintained at the facility files] which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/14/2026 Plan of Correction Administrator stated he/she will read Title 22 to understand the regulation, and to maintain the necessary staff document in the facility.

Official classification

Type A

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(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 in that the fire extinguisher was observed expired which poses an immediate safety risk to persons in care.

Official plan of correction

POC Due Date: 08/29/2025 Plan of Correction Administrator agree to send plan of correction by the POC due date and to install new fire extinguisher immediately.

Official classification

Type A

Official code

87355(e)

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: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in that two volunteers were observed helping residents in the facility without association with the facility which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/29/2025 Plan of Correction Administrator agree to send plan of correction by the POC due date and to associate the two volunteers with the facility.

Official classification

Type B

Official code

87303(c)

Regulation authority

CCR

What the official deficiency says

(c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in that the window screens in a resident room and in a bathroom were oberved needed to repair which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/04/2025 Plan of Correction Administrator agrees to send plan of correction by the POC due date and to repair the window screens.

Official classification

Type B

Official code

87465(h)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in that 2 out 2 residents' centrally stored medication forms were observed inaccurate which poses/posed a potential health, safety risk to persons in care.

Official plan of correction

POC Due Date: 09/04/2025 Plan of Correction Administrator agrees to send plan of correction by the POC due date and to provide staffing for medication to ensure the centrally stored medication forms are maintained accurate.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review ... 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... This requirement is not met as evidenced by: Based on record review and interview, the Licensee did not ensure S2 obtained a Criminal Background Clearance prior to working at a licensed facility which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.

Official plan of correction

Licensee/Administrator stated to submit a written plan of action understanding regulation and will ensure to obtain a Criminal Background Clearance for S2 prior to working in the facility by POC due date. Licensee/Administrator agreed and understood.

Deadline recorded: Jan 31, 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 is not met as evidenced by: Based on record review and interview, Licensee did not maintain staff file for S2 at the facility and was not available to the licensing agency for review which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator stated to submit a written plan of action understanding regulation and will ensure staff files are maintained at the facility and be available to the licensing agency for review by POC due date. Administrator agreed and understood.

Deadline recorded: Jan 6, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. LPA observed that behind the shed, closest to the deck, had several tools and a red container of gasoline. LPA's also observed behind the shed closest exit #3 had a container of lighter fluid. This poses an immediate health, safety or personal rights risk to persons in care

Official plan of correction

POC Due Date: 08/09/2024 Plan of Correction Administrator moved Toxic materials and tools secured them into the locked toolshed during visit. ADM stated she will send a letter of understanding regarding the regulation. ADM will sent to LPA by POC date, August 9, 2024.

Official classification

Type B

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, the licensee did not comply with the section cited above. LPA's observed in the facility backyard between both sheds had several dog droppings. ADM stated residents have activity's in the backyard as well. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/15/2024 Plan of Correction ADM stated she will send a written plan of action on how she will ensure The facility remains clean, safe, sanitary and in good repair at all times. ADM stated she will send the written plan of action, to LPA by POC date, August 15, 2024.

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review the licensee did not comply with the section cited above. LPA observed 4 Out of 5 residents beds had half side rails. LPA requested to see the doctors orders for the bed rails. ADM stated she didn't know she had to get a doctors order for the half side bed rails. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/15/2024 Plan of Correction ADM stated she will get a doctors order for the bed rails. ADM stated she will send documentation orders have been made and will be sent to LPA by POC date, August 15, 2024.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review and interview , the licensee did not comply with the section cited above. Resident R2 & R3 have a neurocognitive disorder. R2 physician's report is dated January 25, 2023 and Needs & services plan is date February 7, 2023. R3's physician's report is dated November 5, 2019 and Needs & Services plan is dated June 21, 2023. ADM stated she does not have updated forms. which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/15/2024 Plan of Correction ADM stated she will send to LPA documentation showing resident R2 & R3's Medical Assessment, and a reappraisal has been updated. ADM stated she will send the documentation by POC date, August 15, 2024.

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: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above. R2's had 4 medication bottles were not listed in the centrally stored medication log. R1 had 1 medication bottle was not listed on the centrally stored medication records. R1 had 3 medications that had incorrect information imputed in the centrally stored medication record. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/15/2024 Plan of Correction ADM stated she will send a letter of understanding regarding the regulation and the importance of maintaining an accurate centrally stored medication record. ADM stated she will send the letter to LPA by POC date, August 15, 2024.

Official classification

Type B

Official code

87412(b)(1)(2)

Regulation authority

CCR

What the official deficiency says

87412 Personnel Records (b) Personnel records shall be maintained for all volunteers and shall contain the following: (1) A health statement as specified in Section 87411(f). (2) Health screening documents as specified in Section 87411(f) This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above. LPA's requested to review V1's health statement & Health screening documents. ADM stated she does not have V1's health statement & health screening documents. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/15/2024 Plan of Correction ADM stated she will send LPA copy of V1's health statement & Health screening documents. ADM stated she will send to LPA by POC date, August 15, 2024.

Official classification

Type B

Official code

87412(g)

Regulation authority

CCR

What the official deficiency says

(g) All personnel records shall be maintained at the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review and interview, the facility did not have personnel records at the facility. ADM stated she has staff records on her computer but due to hard drive issue, it needs to be repaired, so its currently not available. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/18/2024 Plan of Correction ADM stated she will send a plan of action on how the facility will ensure personnel records are maintained at the facility. ADM stated she will send plan to LPA by POC date, 1/18/2024.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the last drill conducted was on July 17, 2023. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/18/2024 Plan of Correction ADM stated she will conduct a drill by next week and send documentation that a drill has taken place to LPA by POC date, 1/18/2024.

Official classification

Type B

Official code

87307(a)

Regulation authority

CCR

What the official deficiency says

Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply This requirement is not met as evidenced by: Deficient Practice Statement Based on interviews conducted with S2, S2 stated he/she sleeps in bedroom #3 with resident R2. ADM confirmed that S2 was sleeping in bedroom #3. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/18/2024 Plan of Correction ADM stated she will send plan of action on how the home will relocate staff S2 and ensure staff do not sleep in the same bedroom with residents. ADM stated she will send plan of action by 1/18/2024.