Excelsior Healthcare Center

Certified administrator requirements and substitute coverage

All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficientnumber of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.This facility was found to be deficient as evidenced by this facility designated Administrator not being aware of a relationship developing between a facility resident and staff person which resulted in a marriage and eventual move out which posed an immediate threat to the Health, Safety, and Personal Rights to the residents in care.

All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69The training shall include, but not be limited to, the following: Psychosocial needs of the elderly, such as recreation, companionship, independence, etc.This facility was found to be deficient as evidenced by the allowance of a facility staff person engaging in a relationship with a facility resident requiring care and supervision which posed an immediate threat to the Health, Safety, and Personal Rights of all residents in care.

Requirement for building permit before construction

87305 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement was not met as evidence by; Based on tour and floor plan review, staff bedroom across dining room converted to a resident and staff bedroom , bedroom #3 and the master bedroom has partition walls inside each of them without blding permits/fire clearance. This poses/posed a potential health, safety or personal rights risk to persons in care.

First aid training requirements

87411 Personnel Requirements - General (c) (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement was not met as evidenced by; Based on record review and interview, S2's first aid training/cpr trainining expired 6/2024. This poses/posed a potential health, safety or personal rights risk to persons in care.

Health screening and fitness requirements

87411 Personnel Requirements - General (f) All personnel, including the licensee and administrator, shall be in good health... verified by a health screening...signed by the examining physician.... This requirement was not met as evidenced by; Based on interview and record review, Staff S2 does not completed heath screening signed by his/her physician though there is a TB/x-ray done. This poses/posed a potential health, safety or personal rights risk to persons in care.

Maintain personnel records at facility location

87412 Personnel Records (g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review.This Requirement was not met as evidenced by Based on record review, ADM stated she did not have staff records for her on-call Administrator. This poses/posed a potential health, safety or personal rights risk to persons in care.

Records available to licensing agency for inspection

87506 Resident Records (d) All resident records shall be available to the licensing agency to inspect, audit, ... during normal business hours....This requirement was not met as evidenced by; Based on interview conducted, ADM stated she could not find R1's file. ADM stated she looked for it but could not provide to LPA to inspect/ Audit. This pose/poses an immediate health, safety or personal rights risk to persons in care.

Maintain facility in clean, safe, sanitary condition

Based on observation the licensee did not comply with the section cited above by not maintaining a clean, safe, sanitary and in good repair and condition the toilet seat rail/grab bar which pose/poses an immediate health, safety or personal rights risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above, R3 and R4 are both under the age of 60. The facility has a census of 5 and capacity of 6. ADM did not send exception request prior to admitting the R3, which poses/posed a potential health, safety or personal rights risk to persons in care.

87461 Mental Condition (a) The facility shall determine the amount of supervision necessary by assessing the mental status of the prospective resident to determine if the individual(5) has a documented history of behaviors which may result in harm to self or others. This requirement is not met as evidenced by:Based on documentations and records reviewed, there is no mental/medical health assessment to address R1’s condition.

87405 Administrator - Qualifications and Duties(d) The administrator shall have the qualifications specified...Sections 87405(d)(1) to (7). If the licensee...all requirements for an administrator... (1) Knowledge of the requirements for providing care and supervision appropriate to the residents. This requirement is not met as evidenced by: Based on the records reviewed and interviews, ADM and staff did not address R1’s mental health condition when R1 was observed by staff ‘looked like R1 had a low energy and less appetite and hard time urinating” prior to the incident.