CREEKSIDE COTTAGE

Official classification

Type B

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

87465(h)(2) Incidental Medical & Dental Care: (h) The following requirements shall apply...(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's observation (see pics) during Annual inspection, the licensee did not comply with the section cited above in finding medication cabinet unlocked, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/17/2025 Plan of Correction Licensee to submit documentation of staff training on regulation 87465(h)(2) with date, time, subject, duration, staff names and signatures of attendance by POC due date 10/17/25 to CCL to clear the citation.

Official classification

Type B

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

87309 (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's observation (see pics), the licensee did not comply with the section cited above in finding kitchen cabinet under sink unlocked, containing cleaning products, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/17/2025 Plan of Correction Cabinet door was locked immediately. Administrator plans to provide an in-service with staff to ensure disinfectants/cleaning solutions are always stored inaccessible to residents in care. Administrator to submit signed log in sheet of trainings with dates by POC due date of 10/17/2025 to clear citation.

Official classification

Type B

Official code

87705(b)(2)(d)

Regulation authority

CCR

What the official deficiency says

87705(b)Licensees shall be responsible for the following: (2)For facilities with fewer than 16 residents (d)The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors…accessible to those residents who may be at risk… This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observation & interview with licensee they did not comply with the section cited above in finding front and back doors accessible to busy road not having auditory device turned on with residents having dementia diagnosis which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/17/2025 Plan of Correction Licensee to submit documentation of staff training on regulation 87705(b)(2)(d) with date, time, subject, duration, staff names and signatures of attendance by POC due date 10/17/25 to CCL to clear the citation.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

(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's record review and interview with Licensee, they did not comply with the section cited above in finding staff (S1) did not have current First Aid certification which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/17/2025 Plan of Correction Licensee/Administrator to ensure all staff have required first aid certification training. Submit proof of staff's first aid certification by POC due date of 10/17/2025

Official classification

Type B

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's/Licensee observation, interview and record review, the licensee did not comply with the section cited above in one resident's (R1) medication Tylenol 650mg expired on March 2024 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/13/2024 Plan of Correction Licensee discarded expired medication immediately. Licensee will submit a written plan addressing how they will ensure PRN medication will be reviewed periodically to discard any expired medication by POC due date 12/13/24 to clear the citation.

Official classification

Type A

Official code

87465(a)(5)

Regulation authority

CCR

What the official deficiency says

87465(a)(5) Incidental Medical and Dental Care. 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: The licensee shall assist residents with self-administered medications as needed. Based off self-reported incident report and interview with Administrator, the PM care staff over medicated the resident on antidepressants. This is an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

Plan of Correction already fulfilled with training with all staff that pass medication. LPA obtained copies. POC cleared.

Deadline recorded: Jan 13, 2023. A deadline is not proof that correction was completed.