College Manor

POSTURAL SUPPORTSBed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.This requirement was not met, as there are 2 full bed rails used for clients #3 and #4, which poses an immediate health, safety or personal rights risk to clients in care. Licensee failed to prohibit the use of full bed rails.

Record centrally stored prescriptions and refill data

INCIDENTAL MEDICAL CARE(h)(6) A record of centrally stored Rx medications for each resident shall be maintained and include names of the resident for whom prescribed, prescribing physician and pharmacist, drug name, strength and quantity, dates filled, started & expiration, prescription number and instructions. This requirement is not met, as medications for client #2 are not recorded on Centrally Stored Medications Record, which poses an immediate health, safety or personal rights risk to clients in care. Licensee failed to ensure that all client medications are logged in CSMR.

Onsite food stock levels for nonperishables and perishables

GENERAL FOOD SERVICESupplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.This requirment is not met, as there is not eough canned fruit and vegetables for 7 day supply. Licensee failed to maintain 7-day supply of canned fruits and vegetables, which poses a potetial health, safety or personal rights risk to clients in care.

Maintain physician order documentation in resident record

POSTURAL SUPPORTSA written order from a physician indicating the need for the postural support shall be maintained in the resident’s record.This requirement was not met, as there are no MD orders on file for half bed rails for clients #1, #2, #3, #4. Licensee failed to maintain MD orders for half bed rails, which poses a potential health, safety or personal rights risk to clients in care.

Document behavioral expression and related causes

Based on observation, interview, and record review the residents appraisal needs and services plans were updated more than 12 months ago which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, interview, and record review the licensee did not provide facility staff with annual training in 2023 which poses/posed a potential health, safety or personal rights risk to persons in care.

Provide resident hot water for personal care

Based on observation and interview the licensee did not comply with the section cited above by having the hot water temperature at 140 degree F which poses/posed a potential health, safety or personal rights risk to persons in care.

Submit and maintain current mailing address

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or ... This requirement was not met as evidenced by: Based on record review, interview, and observation the Licensee did not comply with the section cited above for staff (S1) working and residing in the facility without fingerprint clearance which poses an immediate health, safety, and personal rights risk to persons in care.