Tierrasanta Vernanel Care Home

Keep administrator certification or recertification records

Based on record review, the licensee did not comply with the section cited above in 1 of 1 persons which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on interviews and record review, the licensee did not comply with the section cited above in 1 of 4 persons which poses an immediate health, safety or personal rights risk to persons in care.

Based on interviews and record review, the licensee did not comply with the section cited above in 3 of 4 staff/volunteers (S1, V1 and V2) in care which poses/posed a potential health, safety or personal rights risk to persons in care.

Maintain required personnel records for staff

Based on record review, the licensee did not comply with the section cited above in 1 of 4 persons (S1) which poses/posed a potential health, safety or personal rights risk to persons in care.

Maintain cleanliness and prevent incontinence odors

87625 Managed Incontinence: “(b) …the licensee shall be responsible for the following: “(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not ensure that 1 of 3 residents (R1) who was incontinent was kept clean and dry and free of odors from incontinence. This posed an immediate health and personal rights risk to persons in care.

Prohibit false or misleading facility statements

87207 False Claims: “No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility…” This requirement was not met, as evidenced by: Based on records and interviews, during a formal CCLD investigation, Licensee made a false or misleading statement regarding the extent of their knowledge of abuse against 1 of 6 residents (R6). This posed a potential safety and personal rights risk to persons in care.

87211 Reporting Requirements: “(a)(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 of any of the events specified in (A) through (D) below. (D) Any incident which threatens the welfare, safety or health of any resident…” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not submit a written report to the licensing agency and the persons responsible regarding incidents which threatened the welfare and/or safety of 3 of 6 residents (R1, R2, and R6), within seven days of incident occurrence. This posed a potential safety and personal rights risk to persons in care.

Report suspected non-serious physical abuse within 24 hours

87211 Reporting Requirements: “(c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1).” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not report suspected physical abuse affecting 2 of 6 residents (R2 and R6), but not resulting in serious bodily injury to either, to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours. This posed a potential safety and personal rights risk to persons in care.

Complete admission suitability appraisal

87457 Pre-Admission Appraisal: “(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria…” This requirement was not met, as evidenced by: Based on records and interviews, for 3 of 6 residents (R1, R2, and R5), Licensee did not meet/interview the resident and their responsible person to determine the resident’s suitability for admission, prior to admission. This posed a potential health, safety, and personal rights risk to persons in care.

Regular observation and documentation of resident changes

87466 Observation of the Resident: “The licensee shall ensure that residents are regularly observed…” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not ensure that for 3 of 6 residents (R1, R2, and R6) were regularly observed. This posed a potential safety and personal rights risk to persons in care.

Auditory exit monitoring for elopement risk

87705 Care of Persons with Dementia: “(d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement…” Based on records and interviews, 1 of 6 residents (R1) had Dementia and was at risk for elopement, but Licensee did not ensure the facility had an auditory device (or similar staff alert feature) on its exterior doors. This posed a potential safety risk to persons in care.

Facility must keep complete hospice care plan on file

87633 Hospice Care of Terminally Ill Residents: “(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident…” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not maintain at the facility a current and complete hospice care plan for 1 of 3 residents (R1) who was receiving hospice care. This posed a potential health risk to persons in care.

Right to freedom from abuse and neglect

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: “(a) …residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (8) To be free from… mental, physical, or sexual abuse.” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not ensure that 2 of 6 residents (R2 and R6) were free from, mental, physical, or sexual abuse. This posed an immediate safety and personal rights risk to persons in care.

Maintain facility in clean, safe, sanitary condition

87303 Maintenance and Operation: “(a) The facility shall be clean…at all times.” This requirement was not met, as evidenced by: Based on interviews, Licensee did not ensure that the facility was clean at all times. This posed a potential health and personal rights risk for 3 of 3 residents [R1, Resident #2 (R3), and R3] in care.

Clean linen quantity and hygiene supplies

87307 Personal Accommodations and Services: “(a)(3) …The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads…” This requirement is not met, as evidenced by: Based on records and interviews, Licensee did not ensure that 2 of 3 residents (R1 and R3) had clean linen. This posed a potential health and personal rights risk to persons in care.

Must complete individual written admission agreements

87507 Admission Agreements: “(a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any.” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not complete an individual written admission agreement with 1 of 3 residents (R1). This posed a potential personal rights risk to persons in care.

87218 Theft and Loss: “(a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153.” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153. This posed a potential personal rights risk to 6 of 6 residents (R1 through R6) in care.

Bed provision and bedding standards for residents

87307 Personal Accommodations and Services: “(a)(3) …The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (A) A bed for each resident…Each bed shall be equipped with good springs, a clean and comfortable mattress…” This requirement is not met, as evidenced by: Based on LPA observation and interviews, Licensee did not ensure that 1 of 3 residents (R3) had a mattress that was both equipped with good springs and comfortable. This posed a potential personal rights risk to persons in care.

Obtain baseline medical assessment before resident admission

87458 Medical Assessment: “(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.” This requirement was not met, as evidenced by: Based on records and interviews, for 1 of 3 residents (R1), Licensee did not obtain documentation of medical assessment prior to the person’s acceptance as a resident. This posed a potential health risk to persons in care.

Personal assistance and care for required daily activities

87464 Basic Services: “(f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident…such as…bathing…” This requirement was not met, as evidenced by: Based on records and interview, Licensee did not consistently provide 1 of 3 residents (R3) needed assistance with bathing. This posed a potential health and personal rights risk to persons in care.

Admit resident care meeting requirements

87467 Resident Participation in Decisionmaking: “(a) Prior to, or within two weeks of the resident’s admission, 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, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident’s preferences regarding the services provided at the facility.” This requirement was not met, as evidenced by: Based on records and interviews, for 3 of 3 residents (R1, R2, and R3), Licensee did not prepare a jointly developed written record of care for the resident within two weeks of the resident’s admission. This posed a potential health, safety, and personal rights risk to persons in care.

Kitchen sanitation against contamination sources

Evidence of rodent activity (rat droppings) were noticed by LPA in the dried goods/pantry area while conducting the facility tour. Based on obserations, the Licensee did not comply with the section cited above in all clients in care (2 of 2) which poses a health and safety risk to persons in care.

Label and preserve medicine compliance standards

2 unsecured cups of medication for a resident were left on a shelf next to the dining table. Based on interviews and observations, Licensee did not comply with the above mentioned regulation, posing a potential health and safety risk for (2 out of 2) clients in care.