WINDROSE CARE HOME

Official classification

Type A

Official code

87465-(h)(1)(C)

Regulation authority

CCR

What the official deficiency says

87465-(h)(1)(C) Incidental Medical and Dental Care-The following requirements shall apply to medications which are centrally stored: Medications shall be centrally stored under the following circumstances: Because of potential dangers related to the medication itself, or due to physical arrangements in the facility and the condition or the habits of other persons in the facility, This requirement was not met as evidenced by: During the LPA's tour with staff, the medication closet was observed by the LPA to be unlocked, and all medications were accessible to residents in care. This is a risk to the health & safety of residents in care.

Official plan of correction

Licensee/Administrator to ensure all the medications are locked and inaccessible to residents in care at all times. Licensee will hold an in-service training on " CentrallyStoring Medications " . Submit plan of correction by 2/1/2025. Submit proof of training by 2/12/2025. Include trainer, topics, date/time spent, attendees. POC due 2/1/25.

Deadline recorded: Feb 1, 2025. 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 and Access- 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 was not met as evidenced by: LPA observed the door leading into the garage unlocked, leaving disinfectants, soaps, cleaners, accessible to residents in care. This is a risk to the health & safety of all residents in care.

Official plan of correction

Licensee/Administrator to ensure all cleaner/disinfectants/soaps, items that pose a risk to residents in care are locked and inaccessible to residents at all times. Licensee will hold an in-service training on " Storage space for cleaners/disinfectants/soaps, such items of risk to residents " . Submit plan of correction by 2/1/2025. Submit proof of training by 2/12/2025. Include trainer, topics, date/time spent, attendees. POC due 2/1/25.

Deadline recorded: Feb 1, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(6)

Regulation authority

CCR

What the official deficiency says

87468.2(a)(6) Additional Personal Rights of Residents in Privately Operated Facilities-In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To make choices concerning their daily lives in the facility. This requirement was not met as evidenced by: LPA's investigation, review of records, including interviews with staff and other parties; The investigation revealed that a staff/caregiver had put a resident’s television on a timer to shut off at a specific time in the evening. In summary, staff, S4, stated the resident watches television late into the night, and they are always tired the next day;Resident had no knowledge the television having been put on a timer. This is a risk to personal rights of the resident.

Official plan of correction

Licensee to ensure all staff obtain personal rights/residents rights training. Submit proof of training by 1/24/25, include trainers name, date/time spent, topics covered. POC due by 1/24/25.

Deadline recorded: Jan 24, 2025. 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

(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 LPAs observation, Garage door was not locked, and left all cleaners, soaps, disinfectants, accessible to residents in care, 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: 04/17/2024 Plan of Correction Licensee to ensure that the cleaners, soaps, and disinfectants are kept locked and inaccessible at all times to residents in care. Submit plan on how this was corrected, include pictures with plan of correction. POC due 4/17/24.

Official classification

Type A

Official code

1569.69(a)(3)

Regulation authority

HSC

What the official deficiency says

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (3) An employee shall be required to complete the training requirements for hands-on shadowing training described in this subdivision prior to assisting any resident in the self-administration of medications. The training and instruction described in this subdivision shall be completed, in their entirety, within the first two weeks of employment. This requirement is not met as evidenced by: Deficient Practice Statement Based on record reviews, staff lack completed required medication training hours, for staff that handle medications, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/17/2024 Plan of Correction Licensee will ensure that staff that handle medications have all required medication training per health & safety code. Submit plan of correction for staff to obtain required medication training hours, and submit proof of training by 4/30/24. Plan of correction due 4/17/24.

Official classification

Type B

Official code

1569.625(b)(1)

Regulation authority

HSC

What the official deficiency says

(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. This requirement is not met as evidenced by: Deficient Practice Statement Based on record reviews, five (5) out of five (5) care staff lack completed initial 40 hour required training for, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/06/2024 Plan of Correction Licensee to ensure all staff obtain and complete required forty (40) hour training required per health and safety code. Submit proof of staff having completed all training by POC due date of 5/6/24.

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 LPAs record reviews, Administrator was not able to provide any documentation of having held emergency quarterly drills, on every shift, as required, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/30/2024 Plan of Correction Licensee to ensure drills are completed quarterly as required, and document the drills to record them as needed. Submit plan of correction to ensure facility is in compliance by POC due date of 4/30/24.

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 LPAs observation a resident bathroom sink had a leaking pipe undrneath, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/19/2024 Plan of Correction Licensee to ensure the pipe underneath the sink in the resident bathroom gets repaired and/or replaced to ensure it is in good working order. Submit how this was corrected. POC due 4/19/24.

Official classification

Type B

Official code

87618(b)(3)(B)

Regulation authority

CCR

What the official deficiency says

Gas and Liquid 87618(b)(3)(B)- Oxygen, “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPAs observation , the facility didn't have required " Oxygen in Use " signage in appropriate areas, Oxygen is being used in the faciility, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/19/2024 Plan of Correction Licensee to ensure that " Oxygen in Use " signage is posted in and out of the facility; Submit how this was correceted by POC due date 4/19/24.

Official classification

Type B

Official code

87705(j)

Regulation authority

CCR

What the official deficiency says

The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPAs observation of the front door and slider patio door's alams not working properly, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/19/2024 Plan of Correction Licensee to ensure that all exits, including the front door and slider door have auditory alarms working as required. Submit plan of correction by due date of 4/19/24.