Vanessa Care Home Ii

Health screening and fitness requirements

PERSONNEL REQUIREMENTS--GENLAll personnel...shall be in good health, & physically & mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than 6 months prior to or 7 days after employment or licensure. A report shall be made of each screening, signed by the examining physician. This requirement is not met, as there is no TB test result for Staff #3 & #4 & no health screening for staff #4.

Annual routine visit with medical professional

REAPPRAISALSThe licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every 12 months, either in person or by video appointment. Documentation of the annual routine visit, such as a visit summary, shall be added to the resident's record. record. This requirement is ot met, as MD reports for clients #2 and #4 are dated more than 12 months ago. Licensee failed to ensre that annual routine medical evaluations are documented, which poses a potential health, safety or personal rights risk to clients in care.

Freedom to leave and not be locked in

PERSONAL RIGHTSResidents have the personal right..to leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This requirement is not met, as glass sliding glass door in room #1 is secured with a screw & wood stick so client cannot access the door to exit.Side yard gate on south side is padlocked.Licensee failed to ensure that exits are accessible to clients, which poses an immediate health, safety or personal rights risk to clients in care.

REAPPRAISALSThe pre-admission appraisal...shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first.... and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met, as appraisals for clients #2, #3, #4 are dated more than 12 months ago. Licensee failed to ensure that appraisals are updated annually.

HEALTH & SAFETY CODEAll RCFEs shall provide training to direct care staff on postural supports, restricted conditions or health services, & hospice care...training shall include all of the following: 4 hours of training on the care, supervision, and special needs of those residents, prior to providing direct care to residents... This requirement is not met, as there is no evidence that staff received training on restricted health conditions, which poses a potential health, safety or personal rights risk to clients i care.

Prohibit false or misleading facility statements

FALSE CLAIMSNo licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.This requirement was not met, as certificates of first-aid training for 4 staff were falsified. Licensee disseminated false information regarding first-aid training for staff, which poses an immediate health, safety, or personal rights risk to clients in care. National CPR Foundation certificates of completion for staff #2, #3, #4, #6 observed 9/20/24 are dated 5/11/25.

Health screening and fitness requirements

PERSONNEL REQUIREMENTSAll personnel... shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than 6 months prior to or 7 days after employment or licensure.This requirement was not met, as there is no health screening and TB test result for staff #2. Licensee failed to ensure that all staff have health screeningTB test result, which poses a potential health, safety or personal rights risk to clients in care.

HEALTH AND SAFETY CODE... training requirements shall...include an additional 20 hours annually, 8 hours of which shall be dementia care training...& 4 hours of which shall be specific to postural supports, restricted health conditions, & hospice care, as required by subdivision (a) of Section 1569.696. This requirement was not met, as it cannot be determined if staff have received at least 8 hours of dementia training and 4 hours of annual hospice, restricted health conditions, and postural supoorts training, which poses a potential health, safety or personal rights risk to clients in care.

Heat occupied rooms to minimum temperature

Maintenance and Operation - (b) A comfortable temperature for residents shall be maintained at all times. (1) The facility shall heat rooms that residents occupy to a minimum of 68 degree F, (20 degrees C). This regulation has not been met as evidenced by: Based on observations made, interviews conducted, and temperature readings taken and observed, the temperature is mainly 65F in some areas. The temperature does go down further to around 63F near rooms 4 and 5. These readings and observations made do not meet the minimum temperature of 68F as outlined in regulations. This poses a potential health and safety risk to residents in care.

Based on staff record review, the licensee did not comply with the section cited above, as there is no evidence that caregivers have received required 8 hours of annual medications training. This poses a potential health, safety or personal rights risk to persons in care.- There is no evidence that staff #4 and #5 have received required 8 hours of annual medications training.

Health screening and fitness requirements

Based on staff record review, the licensee did not comply with the section cited above in 2 out of 5 staff records reviewed, which poses a potential health, safety or personal rights risk to persons in care.- Health screenings and TB test results for staff #2 and #4 are not on file.

Store centrally held medications in locked secure place

Based on observation, the licensee did not comply with the section cited above in 1 out of 5 resident rooms, as Centrum multivitamins, Vitamin C, Milk of Magnesia, Tylenol and Magnesium are stored in room #3, where client #1 resides.Client is not able to self store and administer medications, per MD.This poses an immediate health, safety or personal rights risk to persons in care.

Based on staff record review, the licensee did not comply with the section cited above, as there is no documentation that caregivers have received required 8 hours of annual dementia training and 4 hours of annual hospice care, restricted health conditions, and postural supports training.This poses a potential health, safety or personal rights risk to persons in care.

Maintain physician order documentation in resident record

Based on client record review, the licensee did not comply with the section cited above, as there is no MD order for half bed rails for client #4, which poses a potential health, safety or personal rights risk to persons in care.

Based on client record review, the licensee did not comply with the section cited above, as client #5 is diagnosed with dementia, and appraisal is dated in 2019. This poses a potential health, safety or personal rights risk to persons in care.

Ensure hazardous items are locked and not unattended

Based on observation, the licensee did not comply with the section cited above, as detached storage shed in backyard is not locked, and Lysol liquid cleaner and laundry cleaning fluids are stored inside. This poses an immediate health, safety or personal rights risk to persons in care, as cleaning liquids are not secured.

Freedom to leave and not be locked in

Based on observation, the licensee did not comply with the section cited above in 1 out of 5 residents rooms observed, which poses an immediate health, safety or personal rights risk to persons in care.Client #2 resides in room 1 with a sliding glass door, which is secured with a screw so client cannot access the door "because she escapes," per staff.

Based on observation, door alarms on resident doors; from resident rooms to outdoor passageways were observed to be off which poses an immediate health, safety or personal rights risk to persons in care.

Facility must keep complete hospice care plan on file

Based on record review, facility does not have a hospice plan of operation/ care plan for residents who are receiving hospice services.

Based on record review, facility did not have a plan of operation for residents with dementia.

Based on record review 4/4 residents did not have an updated physician's report done within the last year. 3/4 resident records observed, were residents who have a diagnosis of dementia.

Notify agency before locking doors or gates

Based on observations, LPA observed sharps unlocked and ccessible to residents which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review, administrator was unable to provide LPA with staff training documentation; dementia care, safe food handling, emergency disaster drills, etc.

Based on record review, facility did not have the following information readily available; resident roster with resident date of birth, resident's medication list, resident's emergency contact sheet, and resident needs and service plan (for each resident)

Based on record review and interviews, Administrator acknowledged the facility did not have an infection control plan which poses a potential health and safety risk for residents in care.

Provide resident hot water for personal care

Based on observations, water temperature throughout the facility measured between 85.1 degrees F to 95.7 degrees F.

Passageways and stairways kept clear

Based on obserations, LPA observed furniture on the outdoor passageway which can cause tripping hazards and fire safety hazards.

Ensure hazardous items are locked and not unattended

Based on observations, cabinet with chemicals and toxins were unlocked and accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.

Complete admission suitability appraisal

Based on record review; 4/4 resident records observed did not have an indiviudualized needs and service plan.

Food quality controls and rejected damaged goods

Based on observations, LPA observed an expired gallon of milk in the fridge. In addition, LPA observed open bottles of mayonnaise and mustard in the kitchen pantry.

Notification to department after hospice care starts

Based on record review, facility failed to notify Licensing within five days of the initiation of hospice care for Resident 1 (R1).

Check incontinent residents during high-risk periods

87625 Managed Incontinence: (b)In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (2) Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night.Violation of this regulation is not met as evidenced by: Based on the file reviewed and the interviews conducted, R1 was incontinent and needed max assist with toileting needs, however the facility did not have a care plan to ensure that R1’s incontinent condition and needs can be met. Nevertheless, the administrator indicated that there was no care plan for R1.

87307 Personal Accomodations: (a) Living accommodations and grounds...the facility shall be large enough to provide... accommodations...for the residents... (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice… shall be readily available to each resident...Violation of this regulation is not met as evidenced by: Based on the information collected, the licensee failed to ensure R1 had the necessary supplies available, as evidenced by the administrator using other resident's supplies on another resident. The supplies were not readily available and the administrator acknowledged using another resident’s supplies.

Report specified resident events within seven days

87211 Reporting Requirements: 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 of any of the events specified in (A) through (D) below…Violation of this regulation is not met as evidenced by: Facility failed to report an incident that occurred on January 7, 2022 as required to Licensing. In addition, facility failed to submit a written report within 7 days of the occurrence date of the incident.