Ladera Vista

Maintain physician order documentation in resident record

Based on observation, interview, and record review, the licensee did not comply with the section cited above for 4 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Obtain required California clearance or exemption

(e) All individuals subject to a criminal record review..shall prior to working...in a licensed facility:(2)Request a transfer of a criminal record clearance as specified in Section 87355(c)This requirement was not met as evidenced by: Evidence obtained through LPA observation, record review and interview with staff #1 (S1).This poses a potential health and safety risk to all residents in care.

Store disinfectants separately from food supplies

Based on Licensing Program Analyst Leon's observation, the licensee did not comply with the section cited above in 87309(a)(1) as paints, one (1) saw and two (2) pair of shears were accessible to clients which poses/posed a potential health, safety or personal rights risk to persons in care.

During the tour, LPAs observed half bed rails for non-ambulatory residents in rm #1 and rm #4. LPAs did not observe prescriptions from the doctor for half bed rails in resident's filesThis poses/posed a potential health, safety or personal rights risk to persons in care.

During medication review, LPAs observed residents medications stored without prescription labels which poses/posed a potential health, safety risk for residents in care.

Record dose details and resident medication response

During medication review, LPAs did not observed morning signatures by staff for medication that was administered at 9:00. LPAs reviewed the medications at 11:00am. Admin stated that the 3pm med tech signs off on morning medications. This poses/posed a potential health, safety or personal rights risk to persons in care.

Reporting Requirement 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 specified in Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.

Knowledge of care and supervision requirements

Administrator - Qualifications and Duties The administrator shall have the qualifications If the licensee is also the administrator, all requirements for an administrator shall apply. Knowledge of the requirements for providing care and supervision appropriate to the residents. This requirement is not met as evidence by: The administrator failed to overlook hospice notes on 03/18/21 and failed to provide immediate attention to R1's left heel when the blister first appeared on 03/18/21

Incidental Medical and Dental Care 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.. ...following requirements are met: 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. 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 was not met as evidence by: The failed to have licensed staff administer blood medication after each reading and failed to develop a plan for R1's blood pressure administration.

Regular observation and documentation of resident changes

Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person. This requirement is not met as evidence by: The administrator failed to observed resident in care which resulted in resident having an unstageable wound.