24. Unannounced Visit: Random Annual Copy

Hours:    None

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Facility Type: 740 (RCFE)

Investigation Findings
Licensing Program Analyst (LPA) conducted an unannounced Random Annual visit to the facility. Upon arrival LPA was greeted and granted entrance to facility by Assistant Secretary. LPA explained the purpose of today’s visit i.e. to inspect facility and ensure facility is in compliance with California Code of Regulations, Title 22. The facility is approved for 102, 82 which may be non-ambulatory and 20 bedridden. Building B has also been approved for delayed egress on the second floor only. Facility has a hospice waiver approved for 24 and Dementia Program Plan.

Inspection: LPA accompanied by Assistant Secretary conducted a general overall inspection which included, but was not limited to, the following:

Interior: Checked the property against fire and panic violations; capacity; firearms and ammunition, if applicable; facility’s temperature; indoor passageways; hot water temperature; presence of grab bars for each toilet, bathtub and shower; non skid mats or strips in shower or bathtub; diet quality and quantity necessary to meet resident needs; facility supply of 7 days nonperishable food supply and 2 days perishable supply; items that could constitute a danger are properly stored. Checked for excluded personnel. Disaster Drill conducted December 2016.

LPA requested and reviewed facility’s records to ensure staff have received required training in regards to First Aid and Medication training. LPA checked for dementia training requirements, if applicable; emergency disaster plan; certified administrator; special dementia care in plan of operation if applicable; exceptions and waivers if applicable; specialized skills personnel; if applicable; prohibited health condition; medications are given per physician’s orders and PRNs and centrally stored medicines.

Facility does not handle resident cash resources. Personal property and valuables are stored separate and intact, and are not commingled with facility’s funds or petty cash.

Exterior: The common area used by residents; outdoor passageway area, facility does not have a pool or bodies of water.

The following deficiencies were observed:
1. During visit LPA observed facility does not have approval from Fire Department or CCL to have locked perimeters. LPA observed and took pictures of exit gates throughout the facility to all have locks or be locked. (Immediate Civil Penalty will be issued).
2. During visit LPA observed facility to have locks placed on both delayed egress exit doors one by elevator and one by the caregiver office on the 2nd floor in Building B, which is for Dementia residents only. When LPA pushed the door by the elevator, the alarm went off for 15 seconds but the doors would not open after the 15 seconds were up and staff came and unlocked the exit door and informed LPA that they keep it locked so residents do not fall down the stairs. Facility is only approved for Delayed egress on exterior doors on the 2nd floor in Building B.
3. LPA observed signal system on the 2nd floor in Building B was not operating for room 22A and room 21 A.
4. During tour of facility, LPA could smell a strong urine odor upon entrance on the first floor by beauty parlor in building B.
5. During medication review with med tech/staff #5, LPA observed that resident #7 had refused medication Dok 100 mg on 8/1/17 and 8/2/17, resident’s physician/hospice agency was not notified.
6. Facility conducted last disaster drill on 12/12/16.

Based on the above deficiencies will be cited per Title 22, California Code of Regulations.

An exit interview was conducted with Administrator and a copy of this report along with LIC 811 and Appeal Rights was provided.

Deficiency Type /
Section Number
DEFICIENCIESPLAN OF CORRECTIONS (POCs)
Type A
08/03/2017
Section Cited
87203
Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
During visit LPA observed facility does not have approval from Fire Department or CCL to have locked perimeters. LPA observed and took pictures of exit gates through out the facility to all have locks or be locked. (Immediate Civil Penalty will be issued).
Licensee shall not lock any of the gates throughout the facility as it blocks a fire exit. All gates shall be kept unlocked 24/7. Licensee shall submit pictures and statement of understanding to LPA by POC due date. Civil Penalty will be issued.
Type A
08/03/2017
Section Cited
87705(l)(1)
During visit LPA observed facility to have locks placed on both delayed egress exit doors, one by elevator and one by the caregiver office on the 2nd floor in Building B, which is for Dementia residents only. When LPA pushed the door by the elevator, the alarm went off for 15 seconds but the doors would not open after the 15 seconds were up, and staff came and unlocked the exit door and informed LPA that they keep it locked so residents do not fall down the stairs. Facility is only approved for Delayed egress on exterior doors on the 2nd floor in Building B.All locks shall be immediately removed from the delayed egress doors. 15 second alarms shall work accordingly. Licensee to submit statement of understanding and self certification for delayed egress doors to LPA by
POC due date.
Type A
08/03/2017
Section Cited
87303(i)(A)
Maintenance and Operation. LPA observed signal system on the 2nd floor in Building B was not operating for room 22A and room 21 A.Licensee shall fix or replace signal system. Licensee shall submit receipt or provide name of company and appointment date of when this item will be fixed to LPA by POC due date.
Type A
08/03/2017
Section Cited
87303(a)
Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. During tour of facility, LPA could smell a strong urine odor upon entrance by beauty parlor on the first floor in building B. Licensee to ensure facility is kept odor-free at all times/submit plan/statement of understanding to LPA by POC due date.
Type A
08/04/2017
Section Cited
87465(c)(2)
During medication review with med tech/staff #5, LPA observed that resident #7 had refused medication Dok 100 mg on 8/1/17 and 8/2/17, resident's physician/hospice agency was not notified. Licensee shall have In Service Training with all staff and submit statement of understanding and training log to LPA by POC due date.
Type B
08/11/2017
Section Cited
87705(8)
Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff. Facility conducted last disaster drill on 12/12/16.Licensee shall submit copy of update disaster drill to LPA by POC due date.

 

Source
Facility Report

https://secure.dss.ca.gov/ccld/TransparencyAPI/api/FacilityReports?facNum=336426284&inx=22

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