ATRIA HILLCREST

Official classification

Type B

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 and interview, the licensee did not comply with the section cited above in 4 out of 10 resident centrally stored medication and destruction record did not have start dates which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/29/2026 Plan of Correction The Executive Director agrees to conduct an internal medication audit, provide in-service training for staff on proper documentation procedures, and submit proof of completion to CCLD by the Plan of Correction (POC) due date.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

87463 Reappraisals (a) The pre-admission appraisal...shall be updated in writing as frequently as necessary...to note significant changes in condition...and to keep the appraisal accurate...updated pre-admission appraisal shall be referred to as reappraisal This requirement is not met as evidenced by: Based on interview and record review, R1 had a change of condition on or around 12/02/2024 (hospitalization, UTI, catheter, medication change and increased anxiety/depression) however, the facility did not conduct a reappraisal, which posed a potential health risk to persons in care.

Official plan of correction

Executive Director indicated the facility has already begun using a document to be used upon hospital discharge to indicate whether the resident has had a change in condition. Inservice training was conducted on resident change in condition. POC cleared.

Deadline recorded: Jun 6, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87208(a)

Regulation authority

CCR

What the official deficiency says

87208 (a) The licensee shall have and maintain a current, written definitive plan of operation for the facility...significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval... This requirement is not met as evidenced by: Based on interview and record review, the facility has changed it's policies and Admission Agreement as it relates to care services offered to residents, however no approval was obtained from the Department, which poses a potential health and personal rights risk to persons in care.

Official plan of correction

Executive Director agreed to contact corporate to amend and submit the facility's plan of operation and related documents to CCL for approval by POC due date.

Deadline recorded: Jun 6, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(19)

Regulation authority

CCR

What the official deficiency says

(a) 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: (19)To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies.

Official plan of correction

Executive Director agreed to submit a self-certification letter regarding their plan on ensuring future compliance with section cited.

Deadline recorded: Nov 22, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or 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 as one staff (S1) was not associated to the facility which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 02/11/2023 Plan of Correction The licensee agreed to do the following: 1. Associate staff and submit proof to CCL no later than 2/11/23.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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 observation, the licensee did not comply with the section cited above, as the kitchen drawer in the memory care unit needs repair, the cabinet under the aquarium in the memory care unit needs repair, the towel rack in the shower for room # 242 in memory care was broken and needs repair, a bin in the main kitchen on the 1st floor containing sugar was broken, which poses a potential health and safety risk to residents in care.

Official plan of correction

POC Due Date: 02/17/2023 Plan of Correction The licensee agreed to do the following: 1. Repair identified items. Submit proof to CCL no later than 2/17/2023.

Official classification

Type B

Official code

87211(a)(2)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports...(2) Occurrences, such as..outbreaks..which threaten the...or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile.. This requirement is not met as evidence by: Based on interview, the licensee failed to comply with the section cited above, as the Administrator failed to report to CCL a COVID-19 outbreak which poses a potential health, safety, and personal rights risk to residents in care.

Official plan of correction

The Administrator shall submit the COVID-19 intake information the LPA requested during the inspection for the positive staff and residents and also submit a written memo of understanding of regulation 87211 Reporting Requirements to CCL by 11/14/2022.

Deadline recorded: Nov 14, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87446(f)(1)(c)

Regulation authority

CCR

What the official deficiency says

87464 Basic services (f)(1)(c) " Care and supervision " means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above as R1 left the facility unassisted which poses an immediate health and safety risk to persons in care.

Official plan of correction

ED conducted in-service training regarding safety and elopement protocols and submitted proof to LPA. The POC has been met.

Deadline recorded: Jul 29, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

87211(a)(1)(D) Reporting Requirements. A written report shall be submitted to the licensing agency ... within seven days of the occurrence: Any incident which threatens the welfare, safety or health of any resident. This requirement is not met as evidenced by: Based on interviews and documents received, Administrator failed to ensure the incident reports of four (4) residents during the period of two (2) weeks be received by CCL within 7 days of occurrence which poses a potential health & safety risk to residents in care.

Official plan of correction

Executive Director will provide documentation of Management Staff training and Acknowledgement regarding regulation 87211(a)(1)(D) by 8/30/21.

Deadline recorded: Aug 30, 2021. A deadline is not proof that correction was completed.