LAVENDER HILLS ASSISTED LIVING II

Official classification

Type A

Official code

87705(c)(4)

Regulation authority

CCR

What the official deficiency says

87705(c)(4) Care of Persons with Dementia-Licensees who accept and retain residents with dementia shall be responsible for ensuring: There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs. Based upon observation and interview the Licensee failed to provide enough care staff to ensure the safety and health care needs of 1 of 1 residents who went AWOL. This poses an immediate Health, Safety and/or Personal Rights risk to residents in care.

Official plan of correction

Licensee agrees to create and implement a policy and procedure to ensure accountability of individual staff to ensure they are conducting wellness checks. Policy due to CCL no later than COB on 04/16/2024 Civil Penalty assessed in the amount of $500

Deadline recorded: Apr 16, 2024. 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

(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 observation record review, the licensee did not comply with the section cited above in three out of six file reviewed did not have an order for the postual supports utilized by the residents which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/08/2024 Plan of Correction Administrator will remove all postural supports until orders from a physican indicate the need for postural support.

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, the licensee did not comply with the section cited above in two of six residents did not have an updated medical assessment which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/14/2024 Plan of Correction Administrator will ensure that all residents have annual medical assessments.

Official classification

Type A

Official code

87465(a)

Regulation authority

CCR

What the official deficiency says

87465(a)(4) Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on documentation review, the Licensee did not ensure that (R1) received medications as ordered on 5/25/22, when (R1) received (2) medications,50 mg. Pregabalin and 25 mg. Hydralazine, which posed an immediate health and safety risk to residents in care.

Official plan of correction

Licensee / Administrator agrees to conduct training with all caregivers on the requirements for assisting residents with self-administered medications. LIcensee shall submit the training materials and staff sign in sheet to LPA Calzada as proof of correction by 9/20/2023.

Deadline recorded: Sep 20, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

9746(8)(1)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights (a)(8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs.This requirement was not met as evidenced by: Based on interviews conducted and documentation reviewed, the Licensee did not ensure that resident’s (R1’s) representative/POA was contacted when (R1) was sent to the ER on multiple times between, November 2021- June 2022, which posed a health and safety risk and/or personal rights violation to residents in care.

Official plan of correction

Licensee / Administrator agrees to conduct training with all caregivers on the requirements to notify resident's representative / POA when a resident is sent to the ER. LIcensee shall submit the training materials and staff sign in sheet to LPA Calzada as proof of correction by 9/20/2023.

Deadline recorded: Sep 20, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87724

Regulation authority

CCR

What the official deficiency says

87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5) Change of use of the facility. (A) The licensee may, upon no less than sixty (60) days written notice, evict a resident due to change of use of the facility. (1) In addition to written notice to quit requirements specified in Section 87224(d), written notice to evict due to change of use of the facility shall be made to the resident or the resident’s responsible person and shall include all requirements specified in Section 1569.682(a)(2)(A) through (F) of the Health and Safety Code. This requirement was not met as evidenced by: Based on documentation reviewed, the Licensee did not ensure that they abided by their (60) day notice issued on 5/10/22, and not move residents (and R1) from House #1 to House #2, until on/around 7/10/22, which posed a potential health and safety risk to residents in care.

Official plan of correction

Licensee agrees to review the requirements for eviction procedures and submit a statement of understanding. LIcensee shall submit the statement of understanding in writing to LPA Calzada as proof of correction by 9/20/2023.

Deadline recorded: Sep 20, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(15)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (15) To send and receive unopened correspondence in a prompt manner. This requirement was not met as evidenced by: Based on interviews conducted and documentation reviewed, the Licensee did not ensure that (R1)’s incoming and outgoing mail was processed timely in May 2021 and September 2021, which posed a personal rights violation to residents in care.

Official plan of correction

Licensee agrees to establish a process to ensure all outgoing mail is mailed timely and incoming mail is delivered to residents timely. LIcensee shall submit the process in writing to LPA Calzada as proof of correction by 9/20/2023.

Deadline recorded: Sep 20, 2023. A deadline is not proof that correction was completed.