SARAH'S SENIOR RESIDENTIAL CARE

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

87211(a)(1)(D) Reporting Requirements. The licensee shall send a written report, within seven days, to the licensing agency and the person responsible for the resident when any incident occurs which threatens the welfare, safety or health of any resident. This requirement is not met as evidence by: Based on LPA's records review and interview with the Licensee, Licensee failed to report incident involving C1 that threatened the safety or health of residents. This poses a potential health or safety risk to residents in care.

Official plan of correction

Licensee to ensure incidents are reported per regulation. Also, all staff will review regulation 87211, and conduct training for all staff on reporting requirements. Evidence of completed training to be submitted to CCL by POC date of 4/20/2026.

Deadline recorded: Apr 20, 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/Administrator's observation and interview, the licensee did not comply with the section cited above by having the medication lock key hanging on the wall accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/10/2025 Plan of Correction Administrator removed the key during the visit. Administrator will obtain a lock box and will 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 1/10/25 to CCL to clear the citation.

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 LPAs/Administrator's observation, interview and record review, the licensee did not comply with the section cited above in one out of five resident's (R1) medication, Atorvastatin whole tablet was found loose in the medication container which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/10/2025 Plan of Correction Facility to conduct in-service training for all staff reviewing that handles medications to ensure their understanding about medication management and loose medication are not allowed at any time. Training to include the following information: Date, Training Topic, Name/Job Role, and Signatures by POC due date of 1/10/2025

Official classification

Type B

Official code

87307(d)(4)

Regulation authority

CCR

What the official deficiency says

(4) Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPAs/Administrator's observation and interview, the licensee did not comply with the section cited above by not ensuring that areas of potential hazard are well maintained for residents in care, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/17/2025 Plan of Correction Administrator agrees to provide a plan of action to address the areas of concern to CCLD. In addition, Administrator will submit pictures of correction of the areas of concerns located in the backyard by POC due date of 1/17/24 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 Services. The licensee shall assist residents with self-administered medications when needed. Facility staff failed to give residents' their medications as ordered/prescribed by the Physician. This requirement has not been met as evidence by: Based on records review and interviews R1 received the wrong medication and was provided with another resident's medication in error by staff (S1). R1 was sent to the Emergency Room after taking the wrong medication which poses an immediate risk to the health and safety of residents in care.

Official plan of correction

Administrator submitted proof of medication management training conducted with all staff & will write a plan to ensure resident medications are properly managed. Administrator will submit the updated plan to CCL by POC due date. ***Immediate civil penalty in the amount of $500 has been issued.

Deadline recorded: Mar 8, 2022. A deadline is not proof that correction was completed.