KENWOOD GREENS

Official classification

Type A

Official code

87355(d)(3)

Regulation authority

CCR

What the official deficiency says

(3) The licensee shall submit these fingerprints to the California Department of Justice, along with a second set of fingerprints for the purpose of searching the records of the Federal Bureau of Investigation, or comply with Section 87355(c), prior to the individual's employment, residence, or initial presence in the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that per LPA and Admin review of Guardian roster, staff (S1) does not yet have fingerprint clearance, it is showing as " In Process " per the Guardian roster. S1 has been employed at at facility beginning 8/23/2022. which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/27/2024 Plan of Correction Admin agrees to have S1 cease working at the facility until fingerprint clearance is obtained. Admin agrees that Admin will verify S1 has fingerprint clearance and shows as " Eligible Clearance " before they return to the facility. Per LPA obsevation S1 immediately left facility and ceased working. Deficiency cleared.

Official classification

Type B

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 that LPA and Admin observed pre-poured medications filled in respective residents' pill boxes for the next day and evening, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/12/2024 Plan of Correction Admin to submit LIC9098 self-certifying that they will immediately stop pre-pouring medications. Admin will conduct staff training to ensure staff are aware that the facility does not engage in pre-pouring medications. Admin to submit training log along with LIC9098 by plan of correction 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 LPA observation and Admin interview, the licensee did not comply with the section cited above in that four [4] out of seven [7] residents (R3, R4, R6, and R7) did not have current Appraisals.which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/12/2024 Plan of Correction Admin to consuct resident appraisals for R3, R4, R6, and R7, review appraisal with resident's responsible party and obtain either signature or electronic method of verification via email that the appraisal was reviewed with the residents' responsible party or parties. Admin to submit current appraisals along with method of verification for the R3, R4, R6, and R7 to CCL by plan of correction due date.

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 LPA observation and Admin interview along with LPA and Admin record review, the licensee did not comply with the section cited above in that per LPA observation and Admin interview, facility’s quarterly disaster drills are performed with staff individually; however, the facility has not conducted a disaster drill for every employee within the past quarter. which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/12/2024 Plan of Correction Admin to conduct facility’s quarterly disaster drill with every staff member and submit to CCL the disater drill log showing documentation of the drills which shall include the date of the drill, the type of emergency covered by the drill, and the names of staff participating in the drill, by plan of correction due date.

Official classification

Type A

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

87465(a)(1) INCIDENTAL MEDICAL AND DENTAL CARE. The Licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of the residents. ***Based upon statements and document reviews, this requirement has not been met as evidenced by: R1, malnourished and in frail condition, presented with a sore on 7/12/2022 which prompted the Administrator to request nursing or Hospice care for R1 on 7/13/2022 which did not occur. R1 was not sent out for medical treatment until 7/20/2022 when diagnosed with stage ll and unstageable pressure injuries. * This posed an immediate risk to the health of R1.

Official plan of correction

Administrator shall perform an in-service with her staff to ensure that residents with wounds receive timely home health or Hospice Care and, if not available, that residents are seen by a physician. Proof of training will be provided to CCL by POC date in order to clear the deficiency.

Deadline recorded: Feb 3, 2023. 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

87309(a) STORAGE SPACE. 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. Based upon observations, this requirement has not been met as evidenced by: During the course of complaint investigation, LPA observed laundry room containing window cleaner, detergent, and cleanser on counter and in unlocked cabinet while six residents were present in facility. This posed an immediate risk to their safety.

Official plan of correction

Administration shall provide refresher training for all staff on the requirements of 87309 and will provide proof of completion to CCL by POC date in order to clear the deficiency.

Deadline recorded: Jul 29, 2022. A deadline is not proof that correction was completed.