BUCK SERENITY HOMES

Official classification

Type B

Official code

87465(6)(h)

Regulation authority

HSC

What the official deficiency says

87465 Incidental Medical and Dental Care(h) The following requirements shall apply to medications which are centrally stored: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 This requirement is not met as evidenced by: Deficient Practice Statement Based on [LPA and admin record review and observation, the licensee did not comply with the section cited above in that Centrally Stored Medication Log was not complete for S2 requiring medication administration which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/06/2026 Plan of Correction Facility to submit to CCL plan to complete centrally stored medication logs(CSML) for resident by plan of correction due date 3/06/2026. Completed CSML to be submitted to CCL no later than 3/09/2026

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA and admin observation, the licensee did not comply with the section cited above in Toxins found in two resident bathrooms unlocked under bathroom sink including chemicals found unsecured in bathrooms accessible for residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/06/2026 Plan of Correction Licensee to submit LIC9099 self certifying that all toxins have been removed with pictures OR add lock to facility sinks with pictures to CCL by plan of correction due date 3/06/2026

Official classification

Type B

Official code

87303(i)(1)(A)

Regulation authority

CCR

What the official deficiency says

(i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit. This requirement is not met as evidenced by: Deficient Practice Statement Based on [LPA and admin observation licensee did not comply with the section cited above in 5 out of 5 resident room did not have door signal system on which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/12/2026 Plan of Correction LIcensee to submit plan of how facility will ensure that all signal system alarms for all resident bedrooms are on at all times to CCL by plan of correction due date 3/12/2026

Official classification

Type A

Official code

1569.269(a)(6)

Regulation authority

HSC

What the official deficiency says

§1569.269Enumerated rights(a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs...delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement has not been met as evidence by: Based on records review, observations and interviews conducted Licensee did not ensure to services needs were provided necessary to meet individual care needs which poses an immediate risk to the health and safety of residents in care.

Official plan of correction

Facility to submit plan to register all staff to participate/attend the ombudsman training for personal rights. Facility to submit plan to contact the local ombudsman to facilitate personal rights training for all staff by plan of correction due date. Facility to get the date of the next personal rights training and provide the date to CCL by no later than 2/04/25. Once attendance/ participation is completed facility to submit training certificate or record showing all staff in attendance, hours of attendance, date of attendance, and instructor name. Training to be completed by 3/01/2026.

Deadline recorded: Jan 29, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(4)

Regulation authority

HSC

What the official deficiency says

Basic Services 87464(f)(4) Personal assistance and care...as indicated in the pre admission appraisal, with those activities of daily living such as...bathing... This requirement is not met as evidenced by: Based on record review and interviews Staff refused to give R1 showers due to R1’s large size and facility was not able to provide documentation of shower logs.

Official plan of correction

Licensee to submit self certification that staff will be trained on documenting all bathing needs and refusals for all residents as indicated in their admissions agreement .In addition licensee to submit weekly bathing logs for the following 3 weeks to CCLD Licensee to submit self certification to CCL by Plan of Correction due date of 1/30/2026

Deadline recorded: Jan 29, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA and Admin observation , the licensee did not comply with the section cited above in that Thickener stored under stairs made accessible to residents. Medication fridge unlocked, making medication accessible to residents. Fridge had suppositories(bisacodyl 10mg),and Insulin pen without a label inside ziplock bag in also in fridge.which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/30/2025 Plan of Correction Licensee to submiit LIC9098 self certifying that they will lock refridgerated medications by POC due date 4/29/25. Licensee immedietly threw out thickener in trash, no plan of correction needed.

Official classification

Type A

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 LPA and Admin observation the licensee did not comply with the section cited above in Medications found to be prepoured in small plastic containers and not in its originally received container which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/30/2025 Plan of Correction Licensee to submit LIC9098 self certifying that they cannot pre-pour medication by POC due date 4/30/25

Official classification

Type B

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 LPA and admin observation, the licensee did not comply with the section cited above in that Tiles on vanity in bathroom next to room #4 and around left hand side of kitchen sink observed to have dark black substance present in grout as well as broken tile. Deck ramp on wrap around deck has two sections of plywood. Section of plywood in the middle of ramp bows heavily under pressure, cracking sound when stepped on which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/30/2025 Plan of Correction Licensee to submit pictures showing that deck ramp wood replaced and areas around sink clean with tile repaired by POC due date 5/30/25

Official classification

Type A

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (c)All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69(1)staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA and Admin record review and observation , the licensee did not comply with the section cited above in three out of three: S1,S2, S3 did not have current First AId Certification which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/30/2025 Plan of Correction Facility to submit plan to have S1,S2,S3 complete first aid certification by POC due date. Proof of certification to be submitted to CCL by no later than 5/20/25

Official classification

Type B

Official code

87615(a)(1)

Regulation authority

CCR

What the official deficiency says

87615 (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interviews and record review, the licensee did not comply with the section cited above. Facility retained R1 who had an unstaged wound. Although the injury is not yet staged, it appears to be more than stage 2. Which poses/posed an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/11/2022 Plan of Correction Licensee to ensure all residents are appropriate for licensed level of care; Licensee to review regulation 87615; Licensee to update R1’s needs and service plan; Licensee to obtain physician’s report in which wound is stage. If Licensee wishes to retain, R1, they will need an exemption.