EL RIO MEMORY CARE COMMUNITY

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

Personnel Requirements: (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training.. (1) Staff providing care shall receive appropriate training in first aid… This requirement is not met: Based on review of the facility policy, only one staff on premises is required to receive 1st aid training. This poses a potential risk to the health, safety, or personal rights of persons in care.

Official plan of correction

The facility will change their FIrst Aid policy to show that anyone providing assistance with activities of daily living will be required to be First Aid trained by a qualified professional. Within thirty days, staff will attend First Aid training and the Administrator will submit both a sign-in sheet from that training and a copy of First Aid certificates for all staff who assist residents with activities of daily living. These items shall be submitted to LPA Lindstrom at ellen.lindstrom@dss.gov.ca.

Deadline recorded: Aug 25, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by: Based on facility staff reporting they were unable to provide proper care and supervision due to being understaffed resulting in multiple falls with injury to R1. This poses an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

LPA Jensen has confirmed with the Executive Director that at least 8 new staff members have been hired since this complaint was filed and a new training program " Humanitude " has been implemented. No further plan of correction required.

Deadline recorded: Dec 20, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. This requirement was not met as evidenced by: Based on facility staff not recognizing R1’s severe dehydration resulting in kidney injury. This poses an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

LPA Jensen has confirmed with the Executive Director that at least 8 new staff members have been hired since this complaint was filed and a new training program " Humanitude " has been implemented. No further plan of correction required.

Deadline recorded: Dec 20, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(c)(4)

Regulation authority

CCR

What the official deficiency says

Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: There is an adequate number of direct care staff to support each resident’s ...health care needs as identified in his/her current appraisal. This requirement was not met as evidenced by facility staff stating they were unable to complete all required tasks which included checking on R1 every 30 minutes due to being understaffed. This poses a potential risk to the health, safety and personal rights of residents in care.

Official plan of correction

The Licensee agrees to submit a plan that ensures needs and service plans are followed.

Deadline recorded: Jan 16, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87625(b)(3)

Regulation authority

CCR

What the official deficiency says

Managed Incontinence ...the licensee shall be responsible for the following: Ensuring that incontinent residents are kept clean and dry...This requirement was not met as evidenced by: Based on the Executive Director's confirmation that a resident (R2) was in the common area in soiled clothing. This poses a potential risk to the health, safety and personal rights of residents in care.

Official plan of correction

The Licensee is currently working with R2's physician and a specialist to properly assess and treat conditions causing the aggressive behavior. A revised incontinence care plan was also nimplemented. No further plan of correction required.

Deadline recorded: Oct 8, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87611(c)

Regulation authority

CCR

What the official deficiency says

Prior to accepting or retaining a resident with an allowable health condition as specified in Section 87618...facility staff shall have knowledge and the ability to recognize and respond to problems...This requirement was not met as evidenced by: Based on LPA Jensen's interview, the staff member provided care for a resident with a wound and a resident with a hoyer lift but received no specialized training on the wound care or equipment use. This poses an immediate risk to the health, safety and personal rights of residents in care.

Official plan of correction

The Licensee agrees to send an attestation that all staff providing care for residents will be trained on providing care specific to the residents individual health conditions.

Deadline recorded: Sep 20, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464

Regulation authority

CCR

What the official deficiency says

Basic Services Basic services shall at a minimum include: ...Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by: Based on LPA Jensen's observation multiple residents were observed to be in need of assistance with grooming. This poses a potential risk to the safety and personal rights of residents in care.

Official plan of correction

Licensee agrees to conduct training on personal grooming and to implement measures to document and ensure assistance with grooming occurs.

Deadline recorded: Oct 10, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

Basic Services Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by: Based on LPA Jensen's review of missed medication doses, missed blood pressure readings and a lack of evidence that facility staff was taking actions to address R1's treatment non-compliance. This poses a potential risk to the health, safety and personal rights of residents in care

Official plan of correction

The Licensee has conducted in-service training to improve documentation and communication with physician and responsible parties. No further plan of correction is required at this time.

Deadline recorded: Jan 8, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on LPA Jensen's review of the MAR, R1 did not receive a prescribed medication for a period of 10 days. This poses an immediate risk to the health, safety and personal rights of residents in care.

Official plan of correction

The Licensee has done a complete reorganization of the medication room and the procedures surrounding medication administration along in-service training. No further plan of correction is required at this time.

Deadline recorded: Jan 9, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506

Regulation authority

CCR

What the official deficiency says

Resident Records The licensee shall ensure that a separate, complete, and current record is maintained for each resident. This requirement was not met as evidenced by: Based on LPA Jensen's review of the incomplete Needs and Service Plan and MAR. This poses a potential risk to the health, safety and personal rights of residents of in care.

Official plan of correction

The Licensee or facility staff agrees to send a plan detailing the actions that have or will be taken to remain in compliance by the Plan of Correction due date.

Deadline recorded: Jan 11, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87463

Regulation authority

CCR

What the official deficiency says

Reappraisals The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate....The licensee shall immediately bring any such changes to the attention of the resident's physician and his family or responsible person. This requirement was not based on a comparison of the LIC 602 and Needs and Service Plan. This poses a potential risk to the health, safety and personal rights of residents in care.

Official plan of correction

The Licensee or facility staff agrees to send a plan detailing the actions that have or will be taken to remain in compliance by the Plan of Correction due date.

Deadline recorded: Jan 11, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211

Regulation authority

CCR

What the official deficiency says

Reporting Requirements A written report shall be submitted to the licensing agency... within seven days of the occurrence of ...Any incident which threatens the welfare, safety or health of any resident. This requirement was not met as evidenced by:

Official plan of correction

The Licensee or facility staff agrees to send a plan detailing the actions that have or will be taken to remain in compliance by the Plan of Correction due date.

Deadline recorded: Jan 11, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(f)(4)

Regulation authority

CCR

What the official deficiency says

Basic Services Basic services shall at a minimum include: ...Personal assistance and care as needed by the resident with those activities of daily living such as dressing, eating, bathing. This requirement was not met as evidenced by: Based on LPA Jensen's record reviews and interviews, the records reviewed were inconsistent with facility policyon showering accordig to staff. This poses a potential risk to the health, safety and personal rights of residents in care.

Official plan of correction

The Licensee or facility staff agrees to submit a plan of actions that will or have been taken to stay in compliance with this regulation.

Deadline recorded: Dec 26, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

" The licensee shall assist residents with self-administered medications as needed. " This requirement was not met as evidenced by: Based on record review, R1 was not given a second dose of antiparasitic medication as ordered by a physician, which poses an immediate health and safety risk.

Official plan of correction

Licensee agrees to conduct a staff training regarding medication administration and medication record-keeping by the POC due date. Licensee agrees to email LPA Moleski a copy of the training sign-in sheet. vincent.moleski@dss.ca.gov

Deadline recorded: Dec 22, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

Care of Persons with Dementia Each resident with dementia shall have an annual medical assessment as specified in Section 87458...This requirement was not met based on: LPA Jensen's record review of 2 of 4 resident files which did not contain a current LIC 602. This poses a potential risk to the health, safety and personal rights of residents in care.

Official plan of correction

The Licensee agrees to update all LIC 602's that are over 12 months old and will email an attestation to LPA Jensen that this has been completed by the POC due date.

Deadline recorded: Jan 4, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(26)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA Jensen's observation of the facility food supply, the licensee did not comply with the section cited above in maintaining a 7 day supply of non-perishable food which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/08/2023 Plan of Correction The Licensee will scan and send the food order to LPA Jensen by the POC due date.

Official classification

Type B

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA Jensen's observation of 1 resident room with alcohol and 1 resident room with disinfectants, the licensee did not comply with the section cited which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/11/2023 Plan of Correction The Licensee agrees to conduct an inventory of all resident rooms and remove items in the above listed regulation. The facility agrees to email an attestation by the POC to LPA Jensen that all residnet rooms have been checked.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

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 Jensen's record review of staff files, the licensee did not comply with the section cited above in 2 out of 10 counts which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/04/2024 Plan of Correction The Licensee agrees to have all staff that assist with resident activities of daily living obtain current first aid certifications and will email LPA Jensen proof of correction by POC due date.

Official classification

Type A

Official code

87211(a)(2)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements 87211(a)(2) (a) Each licensee... to the licensing agency such reports as ... the following:(2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes... The Licensee failed to comply with the above regulations as evidenced by Based on records review, interviews and observation, the licensee failed to report an outbreak of scabies within 24 hrs. CCL was not notified of any of the additional cases of scabies and scabies treatment after 08/02/203. This LPA was informed on 10/18/23 that 29 more residents had been treated.

Official plan of correction

Licensee has already replaced the DRS and going forward will conduct quarterly audits to ensure the new DRS is complying with policy. Licensee will also update Infection Control Policy to include a detailed Scabies section that incorporates SCHP recommendations. Licensee will submit an attestation that will include a schedule of the Regional Nurse's quarterly inspection and an outline of the new scabies policy by 10/28/23. The final policy will be be completed and submitted to CCL at kimberly.viarella@dss.ca.gov by 10/31/23

Deadline recorded: Oct 28, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(9)

Regulation authority

CCR

What the official deficiency says

CCR 87465(a)(9) Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed...(9) The licensee shall ensure that infection control practices are maintained in the facility... The Licensee failed to comply with the above regulation: Based on observations, interviews and a records review, the Licensee failed to follow their own infection control plan. Residents suspected of having scabies or showing symptoms of scabies were not separated or isolated. Deep cleanings and vacuuming were not performed. The identification of close contacts was never pursued. This poses/posed an immediate risk to residents in care.

Official plan of correction

Licensee shall conduct training with all staff regarding new infection control policy with an emphasis on scabies prevention. This will be completed by 1122/23. By 10/28/23 Licensee shall submit the date of the all staff training to Kimberly.viarella@dss.ca.gov. Signature sheets of participants will also be included.

Deadline recorded: Oct 28, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87625(b)(3)

Regulation authority

CCR

What the official deficiency says

87625 Managed Incontinence (b) In addition to ...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 ... The Licensee failed to comply with the above regulations as evidenced by: Based on Interviews and observations 6/6 responsible parties stated they had found loved ones in soak adult briefs and/or pants on multiple occasions. 3/5 staff said that incontinent care is not always done as scheduled. This poses/posed an immediate health risk to residents in care during a scabies outbreak.

Official plan of correction

Licensee will increase staffing to meet the needs of the residents in care. They will supply CCL with the hours work log for the week of 7/27/23 and 10/30/23 along with the coordinating schedules showing an increase in Caregiver / Resident Assistant hours. For the immediate POC, Licensee shall submit the names of new hires to kimberly.viarella@dss.ca.gov by 10/28/2023.

Deadline recorded: Oct 28, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(b)(1)

Regulation authority

CCR

What the official deficiency says

87705(b)(1) (b)In addition to ..., Plan of Operation, the plan of operation shall address...with dementia, including: (1) Procedures for notifying the resident’s physician, family members and responsible persons. The Licensee failed to comply with the above regulation as evidenced by: The Licensee failed to follow its own plan of operation. and did not notify responsible parties (RP) about scabies. Based on Interviews and records review in 6/6 instances. This posed an immediate, health, safety and/or personal rights risk to those in care and did not assist in containing the spread of scabies.

Official plan of correction

Licensee shall have all nurses receive training on skin assessment, with emphasis on scabies, to ensure that residents are sent to an MD for an evaluation as soon as scabies symptoms manifest. Licensee shall submit to CCL the date and name of the trainer for these trainings by 10/28/23 Signature sheets for participants will be submitted at a later date.

Deadline recorded: Oct 28, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87211(a)(1)(2)

Regulation authority

CCR

What the official deficiency says

87211(a) Each licensee shall furnish to the licensing... as the Department may require: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident... (2) Occurrences, ...24 hours either by telephone... The Licensee failed to comply with the above regulation when: Based on a review of records, R5 was suspected and treated for scabies on 07/14/23. This was not reported to CCL and pose/posed an immediate risk to residents in care.

Official plan of correction

Licensee shall conduct training for all Resident Assistants and Nurses on reporting requirements. Licensee shall submit the dates of these trainings and the name of he facilitator to kimberly.viarella@ccl.ca.gov by 10/27/23. These trainings must be completed by 11/31/23 and signature sheets will be sent to CCL.

Deadline recorded: Oct 28, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468(a)(3)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was met as evidenced by statements and witness's who observed staff member rughly handling a resident in the shower. Which poses a potential health, safety and personal rights risk to residents in care.

Official plan of correction

Facility has already compleated staff training, and involved staff have been terminated from the facility.

Deadline recorded: Oct 12, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(c)(5)(A)

Regulation authority

CCR

What the official deficiency says

Care, Persons with Dementia 87705(c)(5)(A) (5) Each resident with dementia shall have an annual medical assessment...(A) When any... appraisal, or observation indicates that the resident’s dementia care needs have changed, corresponding changes shall be made in the care... This requirement was not met as evidenced by: Dementia care resident has not had a new LIC 602 since 3/3/2021 and the licensee failed to update the needs and services plan of R1 after R1 was involved in 2 separate resident on resident altercations.

Official plan of correction

Licensee shall identify all the residents requiring updated annual LIC 602's as well as those needed due to change in behavior or condition. Licensee will submit this list to kimberly.viarella@dss.ca.gov by 10/14/2023.

Deadline recorded: Oct 4, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(c)(4)

Regulation authority

CCR

What the official deficiency says

Care, Persons with Dementia 87705(c)(4) (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff...resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement was not met as evidenced by: Sufficient staffing would have provided the opportunity for staff to redirect R1 before either of the 2 situations escalated to violence. Per R1's appraisal, R1 " has a history of physical aggression or violence. "

Official plan of correction

The Licensee shall revisit R1's care plan to determine ways to reduce overstimulation by redirecting R1 to a less populated area /activity. Licensee shall submit new care plan to kimberly.viarella@dss.ca.gov by 10/4/2023.

Deadline recorded: Oct 4, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

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 residents. This requirement was not met as evidenced by: On 11/9/2022 Resident (R1) was observed to have a lump on right buttock. On 11/17/2022, R1 was sent to the hospital. The facility did not provide an explanation of why R1 was not provided timely medical assistance. This poses an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

Administrator will look over the regulation and have training with staff and email LPA Lund proof of training.

Deadline recorded: Mar 15, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(2)

Regulation authority

CCR

What the official deficiency says

The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need…. This requirement was not met as evidenced by: Staff failed to notice Resident (R1) changes and failed to seek medical attention resulting in R1 being diagnosed with stage #4 wound and sepsis. This poses an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

Administrator will look over the regulation and have training with staff and email LPA Lund proof of training.

Deadline recorded: Mar 15, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87211(a)(2)

Regulation authority

CCR

What the official deficiency says

Reporting requirements. (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including :(2) Occurrences, such as epidemic outbreaks...within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement was not met as evidenced by: Based on interview, facility had a total of 15 resident and 2 staff active covid cases between 1/31/22 and 2/13/22 which were not reported to licensing department. This posed an immediate health and safety risk to residents in care.

Official plan of correction

Licensee or designee will conduct staff training on reporting requirements and submit scheduled training date to LPA by POC due date. Training to be completed no more than 2 weeks from date of citation issuance, and proof of completed training to be submitted to LPA prior to citation clearance. Licensee or designee to submit information on previous active COVID cases to LPA by POC due date. Licensee may utilize COVID reporting template provided by LPA during today's visit.

Deadline recorded: Feb 15, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87211(a)(1)(d)

Regulation authority

CCR

What the official deficiency says

each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not meet as evidenced by interviews and documentation LPA'S reviewed nurse's notes on multiple dates that show falls and there is no records to CCL. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Administrator will review Title 22 Regulations Section 87211 and have an In-service training with all Staff regarding Reporting Requirements. Administrator will submit a written plan ensuring that incidents are reported to the CCL office as required according to the Regulation. Signatures of all Staff from the training must be submitted to CCL after training is complete. The plan is due by the POC date of 11/04/22.

Deadline recorded: Nov 4, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705K(8)

Regulation authority

CCR

What the official deficiency says

Care of persons with dimentia 87705K(8)Delayed egress devices shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents and to escort residents who leave the facility. This requirement has not been met as evidenced by: Facility is aware of residents behaviors but no staff was at entrance. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Facility staff has addressed issue with pull chords sounding over egress door. LPA observed the alarm sounding over several pull chords. Facility will train staff on the importance of not missing morning resident checks and send proof to LPA.

Deadline recorded: Oct 14, 2021. A deadline is not proof that correction was completed.