EMBRACING SENIORS

Official classification

Type A

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) A plan for incidental medical and dental care shall be developed by facility. The plan shall encourage routine medical and dental care.... (1) The licensee shall arrange.....for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on interviews and medical records, the licensee did not comply with the section cited above. The licensee did not seek medical attention when R1’s pressure injuries progressively worsened, which posed an immediate health and safety risk to residents in care.

Official plan of correction

The licensee agreed to submit a plan describing how they will ensure residents will receive timely medical care. Submit proof to CCL by due date.

Deadline recorded: Mar 28, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87615(a)(5)

Regulation authority

CCR

What the official deficiency says

(a) Persons who require health services for or have a health condition including, but not limited to, those specified....(5) Residents who depend on others to perform all activities of daily living for them as set forth in Section 87459, Functional Capabilities. This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above. The licensee retained R1 who depended on others to perform all activities of daily living, which posed an immediate health and safety risk to residents in care.

Official plan of correction

The licensee agreed to submit a memo of understanding that you have read Prohibited Health Conditions and Exceptions For Health Conditions. Submit proof to CCL by due date.

Deadline recorded: Mar 28, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(B)

Regulation authority

CCR

What the official deficiency says

(a) Each licensee shall furnish to the licensing agency such reports...(1) A written report shall be submitted...... within seven days of the occurrence of any of the events specified in.....(B) Any serious injury....while the resident is under facility supervision. This requirement is not met as evidenced by: Based on interviews and records review, licensee did not comply with the section cited above. No evidence or confirmation that the licensee submitted the 5/12/2023 SIR, dated 05/25/2023, to CCL. Licensee did not submit an SIR for R1’s fall , which posed a potential health and safety risk to residents in care.

Official plan of correction

The licensee agreed to submit a plan describing how you will ensure reporting requirements are followed. Submit proof to CCL by due date.

Deadline recorded: Apr 3, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87632(d)(2)

Regulation authority

CCR

What the official deficiency says

(d) If the Department grants a hospice care waiver it shall stipulate terms and conditions of the waiver....... (2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally Ill resident..... This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above. There is no evidence/confirmation that the licensee submitted a notification for R1’s 05/24/2023 initiation of hospice care services, which posed a potential health and safety risk to residents in care.

Official plan of correction

The licensee agreed to submit a plan describing how you will ensure notification of the initiation of hospice care services is met within the required time frame. Submit proof to CCL by due date.

Deadline recorded: Apr 3, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(d)(1)

Regulation authority

CCR

What the official deficiency says

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (1) Facility staff shall contact the resident's physician prior to each dose, describe the resident's symptoms, and receive direction to assist the resident in self-administration of that dose of medication. 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. One (1) out of four (4) resident records reviewed observed with PRN medication on hand which was indicated by physician that R3 is unable to determine his/her own need for the PRN medication, and is unable to communicate his/her symptoms clearly. Licensee/staff do not have record of physician contact made prior to administering PRN medication. This poses a potential health, safety risk to persons in care.

Official plan of correction

POC Due Date: 04/03/2024 Plan of Correction Licensee agreed to audit the residents medication, communicate with physician and provide in-service to staff. Submit proof of steps taken to ensure above POC is met.

Official classification

Type B

Official code

87465(d)(2)

Regulation authority

CCR

What the official deficiency says

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) The date and time of each contact with the physician, and the physician's directions, shall be documented and maintained in the resident's facility record. 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. One (1) out of four (4) resident records reviewed observed with PRN medication on hand which was indicated by physician that R3 is unable to determine his/her own need for the PRN medication, and is unable to communicate his/her symptoms clearly. Licensee/staff do not have record of contacts made prior to administering PRN medication. This poses a potential health, safety risk to persons in care.

Official plan of correction

POC Due Date: 04/03/2024 Plan of Correction Licensee agreed to audit the residents medication, communicate with physician and develop instructions foe staff to follow to ensure compliance with above. Licensee agreed to provide in-service to staff. Submit proof of steps taken to ensure above POC is met.

Official classification

Type B

Official code

1569.695(d)

Regulation authority

HSC

What the official deficiency says

(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary. 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. Facility emergency disaster plan was not reviewed/updated. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/03/2024 Plan of Correction Licensee agreed to review facility emergency plan and update as necessary and submit copy to CCL. Licensee shall ensure that the plan is reviewed annual and signed. Submit statement of understanding above section cited.

Official classification

Type B

Official code

87609(b)(4)

Regulation authority

CCR

What the official deficiency says

(b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (4) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident's medical condition(s). This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and observation, the licensee did not comply with the section cited above. R1 is receiving home health services in the facility. No agreement between licensee and home health agency observed on file. This pose a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/03/2024 Plan of Correction Licensee agreed to review section sited and submit in writting how he will ensure future complaince.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

(4)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on medical records, photos, and interviews, licensee did not comply with the section cited. Staff did not provide the necessary care and supervision resulting in R1 sustaining pressure injuries and bruising while in care, which posed an immediate health and safety risk to residents in care.

Official plan of correction

Licensee agreed to submit a plan on how they will ensure that residents are provided 24-hour care and supervision to meet their individual health care needs. Submit to CCL by POC due date. An immediate civil penalty of $500 is warranted in accordance with California Health and Safety Code Section 1548(c)(1)

Deadline recorded: Mar 28, 2024. 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 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. LPA observed knives and scissors stored in an unlocked drawer in the kitchen which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/04/2022 Plan of Correction Staff secured the knives and scissors in a locked drawer. Administrator will provide evidence of training staff on securing dangerous items to CCL on or before 03/04/22.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (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 observation, the licensee did not comply with the section cited above. LPA observed cleaning supplies stored in an unlocked cabinet in the kitchen, an unlocked drawer in the bathroom and an unlocked closet in the hallway, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/04/2022 Plan of Correction Staff secured cleaning supplies in a locked cabinet in the kitchen and in the locked garage. Administrator will provide evidence of staff training regarding securing toxic substances to CCL on or before 03/04/22.