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Inspection visit

Follow-up on corrections

ESTANCIA DEL SOLLicense 3318805462 citations on this visit
2 citations recorded

Inspector’s narrative

What the inspector wrote

Licensing Program Analyst (LPA) Javina George made an unannounced case management deficiencies visit in correlation to complaint control number 18-AS-20200513115313 . The following deficiencies are being cited: Neglect/lack of care and supervision-staff failed to meet resident's needs: Resident #1 (R1) was prescribed to use both a nebulizer machine and oxygen concentrator. During dinner R1 was seated at the bar area and observed by Staff #2 (S2) described R1 as “bluish, coughing choking”. S2 helped R1 back to their room, and informed S1 about R1s condition. S1 responded to R1s room to administer oxygen, which was later confirmed to have been the nebulizer. Staff 3 and 4 were making rounds when they observed that R1 was hooked up to the wrong machine. R1 admitted that there was a “mix up with the machine”. R1 also stated the mix up was with the “wires” and “the hose”. S1 stated that the “wires” and “the hose” were tangled and that it was the first time attempting to connect R1 up to the oxygen machine and must have switched it. S1 admitted to picking up the nebulizer machine and setting it on the table. “I remember panicking”. S1 confirmed that she had intended to put R1 on oxygen. S3 and S4 properly connected R1 to the oxygen machine. Hospice was then called to come out to the facility due to R1 having a “change in condition.” It was also determined that S1 failed to notify facility staff and the hospice agency of the mishap. S1 has received verbal and written counseling and the facility provided all staff training on the difference between an oxygen and nebulizer treatment. In addition the incident described/noted above, the facility failed to follow reporting requirements. The information about the incident of R1 not being hooked up to their oxygen machine as needed, but to their nebulizer was withheld as it was not reported. A deficiency is being cited as the facility did not report the incident as required. An exit interview was conducted and a copy of this report and appeal rights were provided to Lisa Hunt, Executive Director.

Citations

4 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87618(b)(5)Type B

    87618 Oxygen Administration - Gas and Liquid (b).. the licensee shall be responsible for the following: (5) Ensuring that facility staff have knowledge of, and ability in the operation of the oxygen equipment.This requirement is not met as evidenced by: 1 out of 1 times, that licensee did not ensure that staff #1 (S1) knew how to properly operation R1’s oxygen equipment. This poses a potential health, safety and personal rights risk to persons in care.

  • 87633(4)(a)Type B

    87633 Hospice Care of Terminally Ill Residents (4) A description of the area of licensee’s responsibility for implementing the plan including, but not limited to, facility staff duties; record keeping; and communication with the hospice agency, resident’s physician, and the resident’s responsible person(s), if... (A) The plan shall specify all procedures to be implemented by the licensee handling of medication, This requirement is not met as evidenced by: 1 out of 1 times the licensee failed to follow the plan This poses a potential health, safety and personal rights risk to persons in care.

  • 87211(a)(D)Type B

    87211Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence... (D) Any incident which threatens the welfare, safety or health of any resident... This requirement is not net as evidenced by: the licensee failed to report the incident in which staff did not

  • 87468.2(a)(4)Type B

    87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (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: (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. Based on observation and interviews this requirement is not met as evidenced by:

FAQ · About this visit

Common questions about this visit

What happened during the June 20, 2023 inspection of ESTANCIA DEL SOL?

This was a other inspection of ESTANCIA DEL SOL on June 20, 2023. 2 citations were issued: 2 Type B.

Were any citations issued to ESTANCIA DEL SOL on June 20, 2023?

Yes, 2 citations were issued (0 Type A, 2 Type B). The first citation was for: "87618 Oxygen Administration - Gas and Liquid (b).. the licensee shall be responsible for the following: (5) Ensuring tha..."

What type of inspection was this?

This was a other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.