SUNSHINE HEALTH PLACE 2

Official classification

Type A

Official code

87307(a)

Regulation authority

CCR

What the official deficiency says

(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. Storage space used as staff sleeping area. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/23/2026 Plan of Correction Licensee/Administrator agreed to remove bed from the storage space; agreed to not allow staff to sleep in this area. Submit photo.

Official classification

Type A

Official code

87608(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (1) Postural supports shall be limited to appliances or devices such as braces, spring release trays, or soft ties, used to achieve proper body position and balance, to improve a resident's mobility and independent functioning, or to position rather than restrict movement including, but not limited to, preventing a resident from falling out of bed, a chair, etc. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. Resident #1's bed rail was observed positioned in the middle of the bed preventing resident from getting out of bed. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/23/2026 Plan of Correction Licensee/Administrator repositioned the bed rail to the head of the bed during todays visit. Licensee/Administrator instructed staff not to move the bed rail.

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 observation, the licensee did not comply with the section cited above. Resident room #4, and 5 door does not close properly. Also the window blinds in room 4 does not cover the window properly. This poses/posed a potential personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/07/2026 Plan of Correction Licensee/Administrator will have maintenance repair the doors to close properly; new window covering will be installed in bedroom #4.

Official classification

Type A

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above as the fire door was observed to have a door stop installed and in use, however fire clearance specifies " door stops prohibited " which poses an immediate safety risk to persons in care.

Official plan of correction

POC Due Date: 06/12/2024 Plan of Correction Licensee indicated the door will remain closed effective immediately. The door stop will be removed by POC due date and proof of correction will be sent to LPA. LPA advised that if licensee wishes to have the door open, a fire door magnet must be installed and hardwired into the existing smoke detector system. Licensee with communicate with fire inspector if this work is planned.

Official classification

Type B

Official code

87608(a)(5)(A)

Regulation authority

CCR

What the official deficiency says

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above in as 2 residents (Resident #1 & Resident #2) out of 3 total records reviewed have full bed rails installed on their beds, however neither is on hospice and neither have a valid exception on file which poses a potential personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/25/2024 Plan of Correction Licensee will submit physician's orders, LIC 602, and additional supporting documents, along with an exception request to retain Resident #1 and Resident #2 by POC due date.

Official classification

Type B

Official code

87705(g)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (g) As required by Section 87468(a)(12), residents with dementia shall be allowed to keep personal grooming and hygiene items in their own possession, unless there is evidence to substantiate that the resident cannot safely manage the items. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above as Resident #3 (R3), who has a diagnosis of dementia has personal grooming, hygiene items, as well as ointments and creams stored unlocked in their private restroom and R3's physician's report indicates yes, at risk if allowed direct access to personal grooming and hygiene items which poses/posed a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 06/18/2024 Plan of Correction During today's visit, licensee secured these items. Licensee indicated they plan to obtain a physician's report indicating R3 can safely have access to these items. Licensee understands that all creams must have physician's orders and be secured and maintained inaccessible to residents in care.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. 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 one out of five residents (Resident #1) needed an updated medical assessment which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/14/2023 Plan of Correction The Administrator agrees to submit proof that R1 has an updated medical assessment to CCL by 07/14/2023.

Official classification

Type B

Official code

87463(c)

Regulation authority

CCR

What the official deficiency says

87463 Reappraisals (c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. 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 in one out of five residents (Resident #2) had an appraisal older than one year which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/14/2023 Plan of Correction The Administrator agrees to submit proof of an updated appraisal for R2 to CCL by 07/14/2023.

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above in one out of five residents with a half bed rail did not have an order on file (Resident #2) which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/14/2023 Plan of Correction The Administrator agrees to get an order for R2's half bed rail and submit to CCL by 07/14/2023.

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 as cleaning supplies and disinfectants were accessible to residents in the unlocked garage, unlocked cabinet in the kitchen, and unlocked cabinet in the restroom, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/23/2023 Plan of Correction The Licensee secured the items and locked the garage. Licensee understands items that can pose a danger should be inaccessible to residents at all times. Licensee will submit proof of locked cabinets in the garage by 05/23/2023.

Official classification

Type A

Official code

87204(a)

Regulation authority

CCR

What the official deficiency says

87204(a) Limitations-Capacity and Ambulatory Status. A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above, as the facility had seven (7) residents between 11/30/22-12/2/2022 when they are licensed for a maximum of six (6) residents, which poses an immediate health and safety risk to residents in care.

Official plan of correction

The Administrator agreed to do the following: 1. At this time, there are only six (6) residents. Review regulation 87204 and communicate how the facility will maintain voluntary compliance. Submit Statement of Understanding by 12/06/2022. Zero tolerance violation; civil penalty in the amount of $500 is assessed.

Deadline recorded: Dec 6, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

87303(e)(2) Maintenance and Operation. Hot water temperature controls shall be maintained ... attain a temperature of not less than 105 degree F and not more than 120 degree F. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above, as the water temperature measured between 124.3 – 125.7 degrees F, which poses an immediate health and safety risk to residents in care.

Official plan of correction

The Administrator agreed to do the following: 1. Adjust the water tank within the next 24 hours 2. After adjusting the water, keep a five day temperature log and submit to CCL within the next seven days.

Deadline recorded: Dec 5, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87625(b)(1)

Regulation authority

CCR

What the official deficiency says

87625(b)(1) Managed Incontinence. …The licensee shall be responsible for the following: (1) Ensuring that residents who can benefit from scheduled toileting are assisted or reminded to go to the bathroom at regular intervals rather than being diapered. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above, as R1 was double diapered due to their bladder and bowel incontinence, which poses an immediate health and safety risk to residents in care.

Official plan of correction

The Administrator agreed to do the following: 1. Submit a Plan of Action, indicating how staff will care for residents with bladder and bowel incontinence. Submit plan of action no later than 11/3/2022. 2. Hold an in-service training with all staff regarding regulation 87625 Managed Incontinence. Submit sign-in sheet of completed training within the next seven days, but no later than 11/8/2022.

Deadline recorded: Nov 3, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. …Residents … shall have ...the following ... rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency... This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above, as staff failed to follow physician’s orders related to wound care for R1, which poses an immediate health and safety risk to residents in care.

Official plan of correction

The Administrator agreed to do the following: 1. Submit a Plan of Action, indicating how staff will care for residents with bladder and bowel incontinence, as well as those with wounds. Submit plan of action no later than 11/3/2022.

Deadline recorded: Nov 3, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(6)(A)

Regulation authority

CCR

What the official deficiency says

Assistance with self-administered medications shall be limited to the following: Medications usually prescribed for self-administration which have been authorized by the person's physician. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above, as staff administered additional medications to one out of six residents (R2) which poses an immediate health and safety risk to residents in care.

Official plan of correction

The Administrator has agreed to do the following: Complete an in-service medication training for staff. Be sure to discuss reviewing prescription labels. Submit proof of completion to CCLD by 5/7/2021.

Deadline recorded: May 7, 2021. A deadline is not proof that correction was completed.