REDWOOD RETREAT

Official classification

Type B

Official code

87625(b)(3)

Regulation authority

CCR

What the official deficiency says

87625 Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors and incontinence. This requriement not met by licensee as evidenced by: Based on LPA and caregiver observation, the licensee did not comply with the section cited above in that facility and resident rooms have odor of urine, which poses an potential health, safety or personal rights risk to persons in care.

Official plan of correction

Facility to purchase either a new mattress or a mattress in good condiction and is comfortable for residents R1, R2, and R3. Mattresses to be waterproof or have waterproof cover. Additionally, facility will implement an incontinence check schedule that caregivers will follow and chart changes. Proof of purchase or photographic proof of changed mattress with waterproof pads due to CCL by plan of correction due date. Additonally, facility to submit one week of incontenence care checks performed by plan of correction due date. Resident refusals will also be documented.

Deadline recorded: May 4, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's & Administrator's interview & record review, the licensee did not comply with the section cited above in 2 out of 5 staff did not either have Health Screening (S2) or TB test results (S1) which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/27/2024 Plan of Correction Administrator to submit TB test results for S1 and Health Screaning for S2 to CCL by POC due date of 9/27/2024 to clear citation.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

87465(h)(2) Incidental Medical and Dental Care: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees... This requirement is not met as evidenced by: Deficient Practice Statement Based on observation (see pics), the licensee did not comply with the section cited above in finding medications in 2 containers on kitchen counter accessible to persons other then employees. which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/17/2024 Plan of Correction Admin to conduct staff training to ensure that staff know how to properly store centrally stored medication per regulation 87465(h)(2). Admin to submit date of training to LPA by POC due date of 9/17/2024 & . Administrator to submit documentation of staff training on regulation 87465(h)(2) with date, time, subject, duration, staff names and signatures of attendance. POC due date 10/1/2024 to CCL to clear the citation.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

87705(c)(5) Care Persons with Dementia - 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 1out of 5 residents (R1) records reviewed having Dementia did not have an annual medical assessment which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/30/2024 Plan of Correction Administrator agrees to send in proof of current medical assessment for resident R1 and statement they understand regulation 87705(c)(5) by POC due date of 9/30/2024. Administrator will contact LPA is more time is needed for extension.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement ***Based on observation the facility did not have hot water temperature between 105 & 120 F in 1 of 4 resident's bathroom faucets which poses an immediate Health, Safety risk for residents in care. LPA observed hot water temperature in 1 bathroom faucet at 122 degrees F.

Official plan of correction

POC Due Date: 09/06/2023 Plan of Correction Facility to ensure hot water temperature is maintained within regulation - 105 TO 120 F. Facility to submit a LIC 9098 self certification that hot water has been adjusted to be within regulation by POC date of 9/6/2023 & begin monitoring for the next 7 days. Licensee to submit a 7 day log taken from the resident's bathrooms to CCL by 9/13/2023.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) 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. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation disinfectant & cleaning solutions under unlocked kitchen sing & 3 paint cans under residents bathroom sink in unlocked cabinet, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/06/2023 Plan of Correction Licensee to ensure that toxins, disinfectants & other items that constitute danger to residents are inaccessible at all time.Administrator removed paint and stored in locked shed in back of facility and agrees to keep kitchen cleaning solutions locked & maintain toxins locked at all times. Licensee to submit LIC 9098 self certification that all items that constitute danger to residents are locked and will be locked at all times to CCL by POC date of 9/6/2023.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview & record review, the licensee did not comply with the section cited above in 3 out of 5 staff TB tests were not performed which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/20/2023 Plan of Correction Administrator to submit a copy of the TB test with the results with the Proof of Corrections form by POC due date 9/20/2023 to clear citation.

Official classification

Type B

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review, the licensee did not comply with the section cited above in 1 out of 5 residents (R1) did not have a current medical assessment on file which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 09/22/2023 Plan of Correction Licensee agrees to provide evidence of current assesssment to CCL by POC Due date 9/22/2023

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 observation, interview and record review, the licensee did not comply with the section cited above in 1 out of 5 residents (R1) did not have a signed reappraisal within 12 months which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 09/22/2023 Plan of Correction Licensee will submit Reappraisal signed by responsible party to CCL by POC due date 9/22/2023

Official classification

Type B

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview & record review, the licensee did not comply with the section cited above in 1 (R1)out of 2 residents medication review of did not record dosages of medications given which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/13/2023 Plan of Correction Licensee to ensure that all residents' medications are entered on a Centrally Stored Medication Record. Facility to provide CCL with copies of CSMR for all residents' medications by POC date of 9/13/2023. .

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

87411(c )(1) Personnel Requirements – General 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. 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 observation and record review, two out of five staff lacked required first aid certification, the licensee did not comply with the section cited above in two out of five staff which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/13/2023 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 9/13/2023.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

87465(h)(2)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 observation by LPA and staff (see pic) medications for destruction were in unlocked closet next to front door. The medication shoud be centrally stored as required by regulations. This is a health & safety risk and/or a personal rights risk to residents in care.

Official plan of correction

POC Due Date: 09/06/2023 Plan of Correction Administrator to submit documentation they understand regulation by POC due date of 9/6/2023 & then documentation of staff training on regulation 87465(h)(2) with date, time, subject, duration, staff names and signatures of attendance. POC due date 9/8/2023 to Community Care Licensing to clear the citation.

Official classification

Type A

Official code

87465(i)

Regulation authority

CCR

What the official deficiency says

87465(i) Incidental Medical and Dental Care (i) Prescription medications which are not taken.. upon termination of services..are otherwise to be disposed of shall be destroyed. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPAs observation that the facility did not destroy 3 residents medications. which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/06/2023 Plan of Correction Administrator to ensure that facility is following required destruction procedures at all times. Items must be immediately destroyed according to Title 22 procedures. Administrator to sign self-certification that they have reviewed regulation 87456 Incidental Medical and Dental Care. Administrator agrees to send LPA Hansen self certification by 9/6/2023.