PARK VISALIA ASSISTED LIVING

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (a) 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: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by Licensee administer a narcotic medication to R1 in error which poses an immediate health safety and or personal rights risk to residents in care.

Official plan of correction

Licensee agrees to conduct a medication training by POC due date 11/11/25.

Deadline recorded: Nov 11, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.... the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement was not met as evidenced by: Based on interviews conducted and records reviewed R1 left the facility on 6/10/2024. Facility was unaware of residents absence until Visalia Police Department found the resident and notified the facility at 1:31 AM, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator agrees to complete in-service training with all staff to cover the processes the staff should follow regarding Egress Alarms and Residents checks and submit document of training to CCLD. Facility submitted training records ***POC Cleared**

Deadline recorded: Apr 12, 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 observation, the licensee did not comply with the section cited above in 2 out of 8 resident rooms had sharps (knives) which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/03/2024 Plan of Correction Administrator will submit statement of intent to conduct a sweep of the facility and remove any sharps that could pose a danger if readily available to residents and submit a report of findings to CCLD when completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, record review, the licensee did not comply with the section cited above in 1 out of 4 residents medication audit revealed an extra pill in the bubble pack that was not given to resident which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/03/2024 Plan of Correction Licensee to submit state of intent by due date to conduct an in-service training for medication and submit records when completed.

Official classification

Type A

Official code

87411(d)(3)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements – General (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (3) Skill and knowledge required to provide necessary resident care and supervision… This requirement was not met as evidenced by: Based on interviews and record review; facility staff are not following residents care plan for 2-person assist when transferring/ assisting resident with toileting needs.

Official plan of correction

Administrator to provide in service training to staff to ensure staff are following care plan for residents transferring needs and provide proof of training to CCLD by due date. Administrator to ensure proper training is provided to staff before working with residents in care.

Deadline recorded: Feb 14, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(b)(3)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (b) If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication. (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. Review of residents medication and MARs revealed PRN medication was given without proper documentation.

Official plan of correction

Licnesee to ensure a record of each PRN dose is maintained in the resident's record.

Deadline recorded: Oct 27, 2023. 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 observation, the licensee did not comply with the section cited above in 1 out of 1 Disinfectants, cleaning solutions observed in the resident laundry room which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/25/2023 Plan of Correction Staff removed items immediately. Administrator will ensure in service training is provided to staff to avoid future issues.

Official classification

Type B

Official code

87307(a)(3)(C)

Regulation authority

CCR

What the official deficiency says

(C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in 1 out of 1 comforter observed to be soiled which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/31/2023 Plan of Correction Memory Care Executive Director removed bedding for washing and will ensure staff change at least once per week or more often when indicated to ensure that clean linen is provided to resident.

Official classification

Type A

Official code

87411(d)(3)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall… (3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents. This requirement was not met as evidenced by: Based on interviews and record review the Staff did not respond to call signal system in a timely manner.

Official plan of correction

Administrator to provide in service training to staff to ensure staff are responding timely. Facility to implement backup check system to ensure call lights are addressed if staff do not respond timely.

Deadline recorded: Sep 8, 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

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall ... (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Medication that was logged in the Centrally stored medication and destruction record (CSMDR) was not sufficient to meet the administration of medication as directed by the physician. LPA observed CSMDR to be incomplete or missing data.

Official plan of correction

Administrator to submit a statement of intent to provide training to all staff in regard to correct documentation of Centrally stored medication and destruction record (CSMDR). Administrator to conduct medication audits routinely and ensure medication is refilled in a timely manner.

Deadline recorded: Sep 16, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator... When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section... This requirement was not met as evidenced by: A qualified substitute was not designated and present at all times while Administrator was on leave.

Official plan of correction

Citation was cleared prior to visit with change of Administrator

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

Official classification

Type A

Official code

87468.1(a)(11)

Regulation authority

CCR

What the official deficiency says

87468.1(a)(11) Personal Rights of Residents in All Facilities (11)To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This requirement was not met as evidenced by: Interviews conducted by the Department revealed facility was requiring unvaccinated family members to COVID test before entry to the facility for visits.

Official plan of correction

Administrator agrees to follow current COVID protocols as indicated in PINS

Deadline recorded: Mar 1, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87413(a)(2)

Regulation authority

CCR

What the official deficiency says

a)In each facility: (2) Care and supervision of residents shall be provided without physical or verbal abuse, exploitation or prejudice. This requirement is not met as evidenced by: Based on interview and record review, staff did not provided care and supervision when R1 left the facility unsupervised on 09/15/22 at approximately 09:00PM and was located approximately two blocks down from the facility by a pedestrian which poses an immediate health and safety risks to persons in care.

Official plan of correction

Licensee shall to submit a plan detailing steps the facility will take to ensure the requirements are met by the POC due date. Licensee has agreed to submit AWOL in-service training and rooster of staff attendance 09/26/22 to the Department.

Deadline recorded: Sep 25, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports…(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… This requirement is not met as evidenced by: Based on record review: Licensee did not ensure a written report was submitted to the Fresno CCL office within 7 days of occurrence on 08/01/2022, 08/11/2022, 08/13/2022, 08/17/2022 and 08/18/2022. Licensee submitted written report to CCL on 08/29/22 and on 08/30/22, which this poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee agrees to submit a plan detailing steps the facility will take to ensure the requirements of Reporting requirements are met by the POC due date.

Deadline recorded: Sep 16, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met: On 1/13/22, S1 yelled at R1 while caring for R1 which poses an immediate health and safety and personal rights risk to the person in care.

Official plan of correction

Appropriate action was taken on staff. However, administrator submit a plan of correction detailing the steps that will be taken to ensure the regulations will be met in the future. Deficiency cleared.

Deadline recorded: Mar 21, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met: Based on the interviews conducted, staffs and resident confirmed S2 yelled at resident while caring for the resident which poses an immediately health and safety and personal rights risk to the person in care.

Official plan of correction

Appropriate action was taken on staff. However, administrator will submit a plan of correction detailing the steps that will be taken to ensure the regulations will be met in the future to Fresno CCL by 03/12/22.

Deadline recorded: Mar 12, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (a)(2): Residents…shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on observation, the facility did not ensure staff are wearing facial coverings as mandated when it was observed that 1 out of 2 kitchen staff were not wearing facial coverings during the lunch period. This poses a potential health and safety risk to residents in care.

Official plan of correction

By the due date, the Administrator will submit a plan detailing steps the facility will take to ensure S1 wear face mask while in the facility as mandated. The plan shall include S1 training on facial covering and proof shall be submitted with POC.

Deadline recorded: Dec 16, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

87705 (f) (1) The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above when LPA observed knives in memory care kitchen drawer unlocked accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee and caregivers immediately removed the knives from the unlocked kitchen drawer into a locked kitchen drawer. POC cleared during visit.

Deadline recorded: Nov 18, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency... (1) A written report...to the licensing agency and to the person responsible for the resident within seven days of the occurrence. This requirement was not met as evidenced by: Based on record reviews, Licensee submitted late incident reports on the following dates: 7/23/21, 7/27/21 and 8/1/21. This poses a potential health and safety risk to persons in care.

Official plan of correction

Licensee agrees to submit a plan detailing steps the faciltiy will take to ensure incident reports are submitted to the Fresno CCL office and responsible party. The plan will be submitted to the Fresno CCL office by 10/25/2021.

Deadline recorded: Oct 25, 2021. A deadline is not proof that correction was completed.