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.