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HomeMy WebLinkAbout2009-02-10; City Council; 19722 part 2; Receive presentation regarding TERI groupSTATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT (Cont) CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION San Diego Res., 7575 Metropolitan DrSte 109 San Diego, CA 92008 FACILITY NAME: T.E.R.I., INC. OUR WAY DEVELOPMENT CENTER DEFICIENCY INFORMATION FOR THIS PAGE:VISIT DATE: 10/27/2005 Deficiency Type POC Due Date / Section Number 10/25/2005 Section Cited S8087 A Section Cited Section Cited Section Cited DEFICIENCIES 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 Buildings and Grounds - Facility accidentally failed to remove rodent pellets over the weekend. A female client possibly ingested partial pellet. Client had green substance (pellet) on face. This has been corrected with glue strips. Facility properly informed all agencies including poison control. PLAN OF CORRECTIONS(POCs) 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 This has been corrected. Facility to ensure all clients are safe at all times. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. SUPERVISOR'S NAME: Shelley High LICENSING EVALUATOR NAME: Tony Girolftni LICENSING EVALUATOR SIGNATURE TELEPHONE: (619) -767-2300 TELEPHONE: (619) -767-2326 DATE: 10/27/2005 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATUREx ^£A^^^^LtA^t, LdH DATfe-10/25/2965- 110803(1=AS) -(06/04)Page: 2 of 2 STATE OF CALIFORNIA • HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION San Diego Res., 7575 Metropolitan DrSte 109 San Diego, CA 92008 FACILITY NAME: DIRECTOR: ADDRESS: CITY: CAPACITY: TYPE OF VISIT: MET WITH: T.E.R.I., INC. OUR WAY DEVELOPMENT CENTER TERESA MARTIN 305 AIRPORT ROAD OCEANSIDE 135 Case Management Teri Earhardt STATE: CA CENSUS: 131 UNANNOUNCED FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 374600992 775 (760) 433-6024 92054 09/02/2005 10:00 AM 11:30 AM DEFICIENCY INFORMATION FOR THIS PAGE: Type A CIVIL PENALTY INFORMATION: Not Applicable COMMENTS/DEFICIENCIES 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 LPA Tony Girolami conducted case management visit on this day. The purpose for the visit was to an incident that was submitted from T.E.R.I Inc. on 8/23/05. investigate The incident report stated that staff Alan Weir hit a female consumer while staff were transporting consumers. This staff is employed by T.E.R.I. Inc. and inappropriately hit client while client was having a behavior on the bus. A female staff at T.E.R.I Inc. witnessed this and reported incident to management. Staff was immediately suspened and then fired. This is a Type A Title 22 Violation: er> r,or T «~— .;"~ - _r- Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. SUPERVISOR'S NAME: Shelley High LICENSING EVALUATOR NAME: Tony Girolami LICENSING EVALUATOR SIGNATURE ' TELEPHONE: (619)-767-2300 TELEPHONE: (619)-767-2326 DATE: 09/02/2005 _._. __ _ I _ _ ._ _______ I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURBM^fc-i^ f*7tt iJk CUtCsyo DATE: 09/02/2005 Page: 1 of 2 STATE OF CALIFORNIA • HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT (Cont) CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION San Diego Res., 7575 Metropolitan Dr Ste 109 San Diego, CA 92008 FACILITY NAME: I.E.R.I., INC. OUR WAY DEVELOPMENT CENTER DEFICIENCY INFORMATION FOR THIS PAGE:VISIT DATE: 09/02/2005 Deficiency Type POC Due Date / Section Number Type A 09/02/2005 Section Cited 80072 (a) 3 Section Cited DEFICIENCIES 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 Personal Rights - Staff inappropriately hit a consumer while transporting clients on the bus. This staff was immediately suspended and fired. T. E.R.I Inc. properly suspended and fired staff. PLAN OF CORRECTIONS(POCs) 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 This has been already corrected. Staff is no longer employed by T. E.R.I. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. SUPERVISOR'S NAME: Shelley High LICENSING EVALUATOR NAME: Tony Girolafni LICENSING EVALUATOR SIGNATURE: TELEPHONE: (619) -767-2300 TELEPHONE: (619)-767-2326 DATE: 09/02/2005 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: *** SIGNED_**U_^ ,-- <V OAT&-09/G2^095- '&*— LIC309 (FAS) - (06/04)Page: 2 of; STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION San Diego Res., 7579 Metropolitan Dr Ste 109 San Diego, CA 92008 FACILITY NAME: DIRECTOR: ADDRESS: CITY: CAPACITY: TYPE OF VISIT: MET WITH: T.E.R.I., INC. OUR WAY DEVELOPMENT CENTER KRYSTI DEZONIA 305 AIRPORT ROAD OCEANSIDE 30 Prelicensing Terry Ehrhardt and Bill Mara STATE: CA CENSUS: 10 UNANNOUNCED FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 374600992 775 (760) 433-6024 92054 07/22/2005 09:30 AM 10:45 AM DEFICIENCY INFORMATION FOR THIS PAGE: No Deficiency Cited CIVIL PENALTY INFORMATION: Not Applicable COMMENTS/DEFICIENCIES 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 LPA Tony Girolami is conducting pre-licensing visit to increase capacity to 135 from 30. The entire ADC facility has been remodeled with new additions. The ADC now has 15 activity rooms, 9 bathrooms, 5 quiet rooms, two staff offices and a conference room. Room #6 will be used for non-ambulatory and ambulatory clients. All other rooms will be for ambulatory only. Bathrooms hot water temperature was 110 degrees. Medications will be stored and locked in the activity rooms where clients reside. Cleaning products will be stored in hall closet. Fire Clearance was received on 7-19-05 and all other construction permits have been received by CCL. Facility will be licensed effective today 7-22-05 for 135 clients, 16 of which may be non-ambulatory. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. SUPERVISOR'S NAME: Shelley High LICENSING EVALUATOR NAME: Tony Girola^i LICENSING EVALUATOR SIGNATURE: TELEPHONE: (619)-767-2300 TELEPHONE: (619) -767-2326 DATE: 07/22/2005 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: ^-^if Cs^i^JAa %, rW DATE: 07/22/2005i L ^ LIC809 (FAS) - (06/04)Page: 1 of 1 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT CALIFORNIA DEPARTMENT Of SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SJD. R»sW»ntUJ, 7579 Metropolitan Dr St* 109 StnDltgo, CA 82006 FACILITY NAME: DIRECTOR: ADDRESS: CITY: CAPACITY: TYPE OF VISIT: MET WITH: T.E.R.I., INC. OUR WAY DEVELOPMENT CENTER KRYSTI DEZONIA 305 AIRPORT ROAD OCEANSIDE 30 Annual/Random Teri Earhardt STATE: CA CENSUS: 37 UNANNOUNCED FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 374600992 775 (760) 433^024 92054 02/03/2005 09:00 AM 10:30 AM DEFICIENCY INFORMATION FOR THIS PAGE: Type A CIVIL PENALTY INFORMATION: Not Applicable COMMENTS/DEFICIENCIES 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 LPA Tony Girolami conducted random visit. Tour was conducted inside and out. Items reviewed/discussed: Poison and toxics, medications, first aid kit/manual, food supply, smoke alarms, criminal record clearance, record keeping, physical plant and water temperature. Failure to correct the cited deficiencies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. SUPERVISOR'S NAME: Shelley High LICENSING EVALUATOR NAME: Tony Girola LICENSING EVALUATOR SIGNATURE: TELEPHONE: (619) -767-2300 TELEPHONE: (619)-767-2326 DATE: 02/03/2005 I acknowledge receipt of this form and u FACILITY REPRESENTATIVE SIGNATURE: licensing appeal rights as explained and received. USv DATE: 02/03/2005 UCS09 (FAS) - (06/04) STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT (Cont) CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION S.D. RMttMntial, 7875 Metropolitan Dr St. 109 San Otogo, CA 920M FACILITY NAME: T.E.R.I., INC. OUR WAY DEVELOPMENT CENTER DEFICIENCY INFORMATION FOR THIS PAGE:VISIT DATE: 02/03/2005 Deficiency Type POC Due Date/ Section Number Type A 021040005 Section Cited 80010A Section Cited Section Cited Suction Cited DEFICIENCIES 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 Limitations on Capacity and Ambulatory Status - At time of visit LPA counted 37 consumers at day program. The license capacity is 30. The facility Is overcapacity on this day. PLAN OF CORRECTIONS(POCs) 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 Facility must adhere to the license capacity. LPA suggested increasing capacity and gave the necessary infomation to the Assistant Director to complete this process. Other issues that would need to be discussed to that the facility has two bathrooms. One bathroom is allowed for 1 5 consumers. Terry Ehrhardt wHI have facility at license capacity by tomorrow. A plan shall be sent by fax tomorrow on how this can be completed. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may re«uft in a civil penalty assessment. SUPERVISOR'S NAME: Shelley High LICENSING EVALUATOR NAME: Tony Girola LICENSING EVALUATOR SIGNATURE: TELEPHONE: (819) -767-2300 TELEPHONE: (619) -767-2326 DATE: 02/03/2005 I acknowledge receipt of this form and u FACILITY REPRESENTATIVE SIGNATU ppeal rights as explained and received. DATE: 02/03/2005 LIC809 (FAS) - (06104}Page 2 Of 2 ,,r rf? _!j F '• I 'Uort-J '* '" Seeing opportunities, Removing limitations. Imparting hope February 4, 2005 Department of Social Services Community Care Licensing 7575 Metropolitan Dr., Suite 109 San Diego, CA 92108 Attn: TonyGirolami Dear Tony: As of Friday morning, February 4th, we have relocated 8 clients to one of our satellite suites. The facility number is 374601054 (E-F-G), which has a capacity of 45. This should correct the deficiency. You also requested the capacities of the other suites. Facility number 37460093 (I-J-K) has a capacity of 30, and facility number 374601053 (N-O-P) has a capacity of 49. If I may be of any further assistance, please feel free to call me. Sincerely, Terry Ehrhardt Assistant Director Adult Services 3225 Roymar Road • Oceanside, California 920^4 (760) 721-1706 • Fax: (760) 721-9872 • www.teriinc.org NOV 0 7 2( STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION S.D. Residential, 7575 Metropolitan Dr Ste 109 San Diego, CA 92008 FACILITY NAME: DIRECTOR: ADDRESS: CITY: CAPACITY: TYPE OF VISIT: MET WITH: T.E.R.I., INC. OUR WAY DEVELOPMENT CENTER FACILITY NUMBER: KRYSTI DEZONIA 305 AIRPORT ROAD OCEANSIDE 30 Case Management FACILITY TYPE: TELEPHONE: STATE: CA ZIP CODE: CENSUS: DATE: UNANNOUNCED TIME BEGAN: TIME COMPLETED: 374600992 775 (760) 433-6024 92054 1 1/04/2002 DEFICIENCY INFORMATION FOR THIS PAGE: Type B CIVIL PENALTY INFORMATION: Not Applicable COMMENTS/DEFICIENCIES 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 LPA is citing facility for not reporting an incident which took place on 10-17-02. LPA received information that a client was in the T.E.R.I van and was struck in the head by another client with a seat belt. LPA spoke with Teri Ehrhardt, Assistant Director on 11/1/02 in person at the licensed facility # 372003147 and we discussed the incident. Teri Ehrhardt states that she took the information but inadvertently failed to send report. T.E.R.I. Inc is normally quite diligent regarding incident to CCL and it appears that this was an incident that was overlooked. LPA is mailing report for signature on 11/4/02. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. SUPERVISOR'S NAME: Marina Stanic LICENSING EVALUATOR NAME: Tony Gircjpmi LICENSING EVALUATOR SIGNATURE:(A c Jw-\J \-\~^*r —•• — TELEPHONE: 619-767-2300 TELEPHONE: 619-767-2326 DATE: 11/04/2002 I acknowledge receipt of this form and Aiders /s~ FACILJTY REPRESENTATIVE SIGNATU^Ej 'licensing appeal rights as explained and received. 11704/20G2- LIC809 (FAS) • (4/96)Page: 1 of 2 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT (Cont) CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION S.D. Residential, 7575 Metropolitan Dr Ste 109 San Diego, CA 92008 FACILITY NAME: T.E.R.I., INC. OUR WAY DEVELOPMENT CENTER DEFICIENCY INFORMATION FOR THIS PAGE: FACILITY NUMBER: 374600992 VISIT DATE: 11/04/2002 Deficiency Type POC Due Date/ Section Number Type B 11/01/2002 Section Cited 80061 Section Cited DEFICIENCIES 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 Reporting Requirements- Facility inadvertently failed to report the incident which took place on 10/17/02. This should have been reported by the next business day by fax or by phone. Thara was no written follow-up. LPA received the report on 11/1/02 in person. The report was already completed and copied for LPA PLAN OF CORRECTIONS(POCs) 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 All future incidents shall be reported. This incident has been corrected. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. SUPERVISOR'S NAME: Marina Stanic LICENSING EVALUATOR NAME: Tony Girolanpi LICENSING EVALUATOR SIGNATURE: TELEPHONE: 619-767-2300 TELEPHONE: 619-767-2326 DATE: 11/04/2002 I acknowledge receipt of this form and understand my appeal rights-as explained and received..- ^ ~-—K-— fi/* s** FACILITY REPRESENTATIVE SIGNATURE:DATE: 11/04/2002 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION S.D. Residential, 7S7S Metropolitan Dr Sle 109 San Dfego, CA 920M FACILITY NAME: DIRECTOR: ADDRESS: CITY: CAPACITY: TYPE OF VISIT: MET WITH: T.E.R.I., INC. OUR WAY KRYSTI DEZONIA 305 AIRPORT ROAD OCEANSIDE 30 Annual Rob Davis DEVELOPMENT CENTER STATE: CA CENSUS: 16 UNANNOUNCED FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 374600992 775 (760) 433-6024 92054 09/26/2002 11:15AM 12:00 PM DEFICIENCY INFORMATION FOR THIS PAGE: No Deficiency Cited CIVIL PENALTY INFORMATION: Not Applicable COMMENTS/DEFICIENCIES 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 LPA Tony Girolami conducted annual visit and met with staff Susan Davis, Randy Weaver, Rick Carter, Rob Davis. Staff was eating lunch with clients during visit. Items reviewed: Poison and toxics, medications, smoke alarm, water temperature, activities, physical plant, record keeping and incident reporting. All staff have seen the Abuse reporting video. T.E.R.I Inc. makes this part of their new hiring practices and ensures all staff see the video prior to having contact with clients. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. SUPERVISOR'S NAME: Marina Stanic LICENSING EVALUATOR NAME: Tony Girolami LICENSING EVALUATOR SIGNATURE: /I/ TELEPHONE: 619-767-2300 TELEPHONE: 619-767-2326 DATE: 09/26/2002 I acknowledge receipt of this form and understencLmyJicensing appeal rights as explained and received. FACIUTY REPRESENTATIVE SIGNATURE: (C L~ J~^~^ -» DATE: Q9/26/2002 Page: 1 of 1 DEC 2 6 2001 STATE OF CALIFORNIA • HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SD Residential, 7575 Metropolitan Dr Ste 109 San Diego, CA 92108 FACILITY NAME: DIRECTOR: ADDRESS: CITY: CAPACITY: TYPE OF VISIT: MET WITH: T.E.R.I., INC. OUR WAY DEVELOPMENT CENTER FACILITY NUMBER: KRYSTI DEZONIA 305 AIRPORT ROAD OCEANSIDE 30 Annual Terry Ehrhardl FACILITY TYPE: TELEPHONE: STATE: CA ZIP CODE: CENSUS: 4 DATE: UNANNOUNCED TIME BEGAN: TIME COMPLETED: 374600992 775 7604336024 92054 12/14/2001 1 1 :00 AM 12:OOPM DEFICIENCY INFORMATION FOR THIS PAGE: No Deficiency Cited CIVIL PENALTY INFORMATION: Not Applicable COMMENTS/DEFICIENCIES 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 LPA Tony Girolami conducted annual visit and met with Terry Ehrhardt. Tour conducted Items reviewed/discussed: Poison and Toxics, medications, first aid kit/manual, hot water and physical plant. Sample record review conducted. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. SUPERVISOR'S NAME: Patrick Smith LICENSING EVALUATOR NAME: Jeff Jirolami ^ LICENSING EVALUATOR SIGNATURE: *** SlGWEQ/Vsi TELEPHONE: 714-703-2840 TELEPHONE: 619-767-2326 DATE: 12/14/2001 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: "'SIGNED*** , --- / PATEri2/14/2001 LIC809 (FAS) - (4/96)Page: 1 of 2 S'TATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT See other side for explanation of form. VPE OF VISIT: L4-t)FFICE [j EVALUATION D PRELICENSING LLANNUAL D FOLLOW-Mc DEFICIENCY INFORMATION FOR THIS PAGE: D TVPe A S-1^Deficiency Cited D Type B UNANNOUNCED | TIME COMPLETED CIVIL PENALTY INFORMATION: J^: Penalty Assessed D Penalty Notice Given COMMENTS/DEFICIENCIES Failure to correct the above cited deficiency(ies), on or befoTe^heTlarvoTc^rTT ^ ~ assessment of $50 per day (Family Child Care Homes, Foster Familv Homo* f „" ( C) due date' maV resultassessment of $50 per day (Family Child Care Homes, Foster Famlly^omwTrJd an" (P°C) *"* date' may result in a civ -/ — governmental agencies are exemot)i irpWKiww PVAI MiTTin QicwflTi IDC t ^^, r-r., ,^.,- r^— 'r*f- Ifcenstng'appeal rights as lained on th of this form. Pay - Deficiencies/Violations on TERI Inc. homes investigated and reported by the Department of Health and Human Services: 11/20/08 Failed to ensure clients had a change of clothes at day program in event their clothes became soiled. 11/20/08 Failed to ensure current consents were obtained for clients medical, dental, and surgical treatment, disposition of clothing, visitation, use of a house alarm, locking up of cleaning supplies, and use of the house pool. 11/20/08 Failed to endure that clients had a recreational therapy assessment prior to their annual interdisciplinary meeting to develop their individual service plan. 11/20/08 Failed to ensure clients had an annual EKG as ordered by physician. 11/20/08 Failed to ensure clients had an annual dental examination. 11/20/08 Failed to ensure medications that had expired were removed from use. 11/20/08 Failed to ensure the temperature of the hot water in client's bathrooms did not exceed 110 degree Fahrenheit. 11/20/08 Failed to sure fire drills were held for each shift of personnel each quarter. 11 /20/08 Failed to ensure all staff members were knowledgeable of location of main gas shut-off valve. 9/25/08 Failed to provide training to direct staff related to clients who required to have epi-pen (auto-injector of epinephrine) for persons at all times for an allergic reaction to bee stings. Staff was unaware of epi-pen and its use. 9/25/08 Failed to store medications under proper conditions. 9/25/08 Failed to ensure only authorized persons had access to the control medication. As a result one of the clients had access to the control medication key. 9/25/08 Failed to ensure tooth brushes were stored in a manner to prevent ^examination. 9/25/08 Failed to have clients receive appropriate staff modeling to assist in eating skills when staff did not sit at the table with the client. 4/11/08 Failed to ensure that informed consent was obtained for "Cleaning supplies locked up" for clients. 4/11/08 Failed to implement program as written for clients. 4/11/08 Failed to serve variety of foods as written on the evening dinner menu. 3/29/08 Failed to notify the Department of an unusual occurrence within 24 hours. 2/28/08 Facility failed to develop health care plans although recommended by physicians. 12/21/07 Failed to maintain dental summary of the annual dental visit in clinical record which resulted in failure to know when appointment was or what occurred at the appointment. 12/21/07 Failed to assure all drugs were administered in accordance with the physician's orders. 12/21/07 Failed to provide clients one of five planned categories of food that menu listed. 12/14/07 Facility failed to ensure that only authorized personnel had access to drug/storage areas. 12/14/07 Failed to develop and maintain a record keeping system that documented the doctor's reviews of all laboratory tests results. 12/14/07 Failed to ensure a current written consent for medications were obtained. 12/14/07 Failed to ensure clients receive annual dental exams. 12/14/07 Failed to maintain adequate supply of emergency water to meet clients and staff minimal water needs for 3 days in event of disaster. 12/13/07 Failed to obtain consent forms for clients. 12/13/07 FailedTo^slJre^ahimaTEKG exams were done for clients. 12/13/07 Failed to ensure testing was done for RN in accordance with facility's policy and procedures on employee testing. 12/13/07 Failed to assure clients did not have access to water temperature control dial of the water heater. 12/13/07 Failed to have detailed plan to specify amount of water necessary for client in even of disaster or emergency. 6/8/07 Failed to ensure informed consent for medical, surgical, and dental treatment were obtained in timely manner for clients. 6/8/07 Failed to provide awake overnight staff for clients with history of aggressive and assaultive behavior and of being a security risk. 6/8/07 Failed to ensure clients had annual dental examinations. 6/8/07 Failed to ensure that all drugs were administered without error for clients. 6/8/07 Failed to ensure only authorized personnel had access to drug storage areas. 6/8/07 Failed to ensure labeling of medication with accordance w/ accepted professional practices. 6/8/07 Failed to remove from use of medications that were outdated and other medications with no known expiration dates. 6/8/07 Failed to ensure weather temperature in client's bathroom did not exceed 110 degrees Fahrenheit. 6/8/07 Failed to ensure all staff were able to locate the shut-off valve and be able to shut off the main gas supply to the facility. 5/23/07 Failed to provide awake direct staff. 5/23/07 Failed to designate a community member to sit on the Human Rights Committee who has no interest in the facility. 4/27/07 Failed to provide awake direct staff (DCS) at night for clients with a record of being aggressive. 4/27/07 Failed to have adequate amount of water supply to meet the needs of clients and staff during an emergency. 4/6/07 Failed to implement individual service plan as written for client. As a result, direct care staff used more restrictive methodology than what was required. 4/6/07 Staff failed to complete documentation required-failed to enter a behavior occurrence in the data collection system for client. 4/6/07 Failed to report an alleged physical abuse immediately, as directed by facility's policy and procedures. 4/24/06 Failed to provide awake overnight staff. 2/2/07 Failed to provide current consents. As a result, there was no current consent for clients' medications used to control behaviors and no current consents for use of door alarms, locked knives and cleaning supplies. 2/2/07 Failed to ensure that responsible direct care staff were awake and on duty when clients were present. As a result, clients with self-injurious behaviors were not supervised during overnight shifts. 2/2/07 Failed to document behavior management plan for clients there were accurate and meaningful. As a result, the data necessary for monthly review of the program was incomplete. 2/2/07 Failed to ensure clients receive health services as ordered by physician. As a result, the client had not had annual screening since 2002 and EKG since 2004. 2/2/07 Failed to ensure clients have individual service plan that did not include goal to increase skills related to medication administration. 2/2/07 2/2/07 -3/8/06- No current consent forms for clients' medications used to control behaviors and no consent for door alarms, locked knives, and cleaning supplies. Failed to ensure direct care staff was awake and on duty when client present. Clients with aggressive, assaultive, elopement and self-injurious behaviors were not supervised during overnight shifts. FailedTorelisurelrifbrrned consents were obtained for restrictive interventions incorporated into adaptive behavioral support plans. In addition, no informed consent was obtained for administration of pre-sedation medication. 2/2/07 Failed to document behavior management plan for clients. Data necessary for monthly review of program was incomplete. 1/19/07 Failed to have community representative participate in the Human Rights committee who has not interest in the facility. 1/9/07 Failed to obtain informed consents for the use of medications for clients. 1/4/07 Failed to obtain consent forms for clients. 1/4/07 Failed to have a community representative participate in Human Rights committee. 1/4/07 Failed to provide annual dental diagnostic services for client. DEPARTMENT OF HEALTH AND HUMAN C.RVICES CENTERS FOR MEDICARE & MEDICAID ^ PRINTED: 12/21/2007 FORM APPROVED OMB NO, 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIERyCLIA IDENTIFICATION NUMBER: 05G600 (XZ) MULTIPLE CONSTRUCTION A. BUILDING 6 WING (X3) DATE SURVEY COMPLETED 12/14/2007 NAME OF PROVIDER OR SUPPLIER MARSHALL HOUSE STREET ADDRESS. CITY. STATE, ZIP CODE 758 SOUTH MELROSE VISTA, CA 92083 PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES ID (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) TAG PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETION CROSS-REFERENCED TO THE APPROPRIATE i DATE DEFICIENCY) W 383 ' Continued From page 8 RECORDKEEPING Only authorized persons may have access to the keys to the drug storage area. 1 This STANDARD is not met as evidenced by: Based on observation, interview and record , review, the facility failed to ensure that only ' i authorized personnel had access to the drug storage areas. I Findings; During an interview and a joint medication record ; review with the house manager (HM) on 12/13/07 at 8:45 A.M., an observation of the medication storage area was made. The HM took out the medication keys from a drawer located in the , dining room. The medication keys were observed in a pink plastic rectangular box along with three bottles of nail polish, nail files and a pedicure ' foam pad. An interview with the HM was conducted on 12/13/07 at 8:55 A.M. •[ stated that the medication keys were KepT in the drawer located . in the dining room, m said that only staff had access to these keys which were used for the facility's locked medications. However, the HM acknowledged that the medication keys were accessible to anyone passing by. interview withthe acknowledgedtna the medication keys were kept in a drawer in the dining room and therefore, accessible to the clients in the house or anyone passing by. W383I \v FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9H4V11 Facility ID: CA090000993 If continuation sheet Page 9 of 13 DEPARTMENT OF HEALTH AND HUMAN CENTERS FOR MEDICARE & MEDICAID <?RVICES PRINTED: 12/21/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 05G600 (X2) MULTIPLE CONSTRUCTION A. BUILDING 8. WING (X3) DATE SURVEY COMPLETED 12/14/2007 NAME OF PROVIDER OR SUPPLIER MARSHALL HOUSE STREET ADDRESS. CITY. STATE. ZIP CODE 758 SOUTH MELROSE VISTA, CA 92083 (X4)ID ' SUMMARY STATEMENT OF DEFICIENCIES ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ,xsiCOMPLETION W 339 • Continued From page 3 ' placed on Client 2's hand without a physician order. As a result, Client 2's palm was not protected from an inward constriction of the hand and Client 3's walking exercise was not done as ordered by the physician. Findings: 1a. Client 2 was admitted to the facility on During general observations at the facility on 12/1 1/07 at 4:05 P.M., 5:20 P.M., 6:40 P.M., and 7:25 P.M., Client 2 was observed without a towel roll in left hand. During a general observation at the day program on 12/12/07 at 10:50 A.M., Client 2 was observed in a classroom with peers, ••was not observed j hanCwith a towel roll in had a wash cloth tucked into^J~pants, •{left hand had a e with •rllefths tan colored splint-like device with a layer of sheepskin that lined the interior. On the same day at 11:10 A.M., the same wash cloth was ' observed on the table. A review of Client 2's clinical record was conducted on 12/13/07 at 9:55 A.M. The physician's orders, dated 10/12/07, indicated that Client 2 was to have a towel roll "placed in left hand at 8am and out at 8pm." It also indicated that the device was to be used when the Client goes on outings and removed only for handwashing A review of Client 2's medication administration record (MAR) was conducted on 12/13/07 at W339 Q FAR? Y^cwv&Moi f\e\ -\Wl~ FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:9H4V11 Facity ID' CA090000993 If continuation sheet Page 4 ol 13 California Department of Public Healti. PRINTED: 11/13/2008 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIOER/SUPPLIER/CUA IDENTIFICATION NUMBER CA090000993 (X2) MULTIPLE CONSTRUCTION A BUILDING B WING (X3) DATE SURVEY COMPLETED 10/30/2008 NAME OF PROVIDER OR SUPPLIER MARSHALL HOUSE STREET ADDRESS, CITY, STATE. ZIP CODE 758 SOUTH MELROSE VISTA, CA 92083 (X4)IO SUMMARY STATEMENT OF DEFICIENCIES ! |0 PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL ; PREFIX TAG : REGULATORY OR i_SC IDENTIFYING INFORMATION) i TAG PROVIDER'S PLAN OF CORRECTION ! (xs; (EACH CORRECTIVE ACTION SHOULD 3E I COMPLETE CROSS-REFERENCED TO THE APPROPRIATE j DATE DEFICIENCY) I B 359 i Continued From Page 1 , and Emergency Information. Client 1 had been i discharged to another care facility on 10/24/08. i Review of the facility Incident/lllness/lnjury ; Report, dated 10/19/08, revealed that at 11:00 P.M. Client 1 had "hit the bathroom door and made, right elbow bleed." Review of the : Interdisciplinary Notes, dated 10/20/08 and signed by the facility Licensed Nurse (LN), revealed that LN had observed Client 1's elbow at the day program, on 10/20/08, and "noted redness and slight swelling of right elbow." Review of the Mobile Physician Services report, dated 10/21/08, revealed that Client 1 had an , abrasion on the right elbow that the elbow was swollen and reddened. The physicians's report ' revealed a prescription for Keflex (an antibiotic medication) and documented "if bursa (joint i tissue) becomes infected, may need drainage". : Review of Client 1's Nursing Care Plan revealed ; no information with regard to care of the elbow injury, medication, or potential for infection. , On 10/30/08 at 7:45 A.M., an interview was ; conducted with DCS 1. DCS 1 stated that(| j observed "a scrape" on Client 1's right elbow the , morning of 10/20/08. DCS 1 stated that the j night staff had told |J that the injury occurred at i the time of a "behavior incident". DCS 1 stated I that the client was seen by the nurse at the day ; program and that "a dressing was to be kept on i the elbow." DCS 1 stated thatJH had not been given a written plan of care for the elbow and that ; "I just tried to keep a dressing on it." DCS 1 ! stated that the Client 1's elbow "was swollen and i had a little drainage" when^J last observed the client on 10/23/08. On 10/30/08 at 10:30 A.M., an interview and joint record review was conducted with the LN . LN stated that Client 1's right elbow injury required a dressing and the client had "sensitive skin and B359 STATE FORM TIXZ11 If continuation sheet 2 of« DEPARTMENT OF HEALTH AND HUMA* CERVICES CENTERS FOR MEDICARE & MEDICAID oERVICES PRINTED: 03/05/2008 FORM APPROVED OMB NO, 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER CARLO HOUSE (X4) ID PREFIX TAG W331 (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY IDENTIFICATION NUMBER: COMPLETEDA. BUILDING 05G650 BWING-02/213/2008 STREET ADDRESS, CITY, STATE, ZIP CODE 411 CARLO STREET SAN MARCOS, CA 92069 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 This STANDARD is not met as evidenced by: Based on interview and record review, the facility failed to develop health care plans for health care issues identified by the Registered Nurse for 3 of 3 sampled clients (1, 2, 3). In addition, there was no sexuality/family life program developed for 3 of 3 sampled clients (1,2,3) after being recommended by their physician on 10/16/07. Findings: 1. Client 1 was admitted to the facility on 1/26/93 with diagnoses that •••^••^H^^^•^•HHHJ^Hpina mi luili ilBBBM^^^B ^^^•^^•^^^^^^^^^irnpulseconToTclisorder accordirjgtome Client Identification and Emergency Information sheet. Client 1's clinical record was reviewed on 2/28/08 at 9:30 A.M. According to the January 2008 monthly nursing summary report, the Registered Nurse (RN) had listed hypertension, extrapyrarnidal symptoms (neurologic side effects (^•••0 medication), enuresis (bed wetttngTanda lesion on the head as identified health care issues for Client 1. However, these health care issues were not incorporated into Client 1's health care plan. There was no mention of these health care issues on Client 1's health care plan. An interview was conducted with the RN on 2/28/08 at 5:05 P.M. The RN acknowledged that the health care plans identified for Client 1 had not been incorporated intoH health care plan. No objectives or approachesnad been developed to address these health care issues. ID PREFIX TAG W331 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) health care plans utilizing objectives and approaches to address all health care issues for Client 1, Client 2 and Clients. The RN shall ensure that the health care plans are maintained. The Director of Residential Services shall monitor through routine Internal auditing. (X5) COMPLETION DATE FORM CMS-2567(02-98) Previous Veratona Obsolete Event ID: DSMS11 Faculty ID: CA090001019 If continuation sheet Page 5 of 11 DEPARTMENT OF HEALTH AND HUWW "ERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 03/05/2008 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 05G650 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 02/28/2008 NAME OF PROVIDER OR SUPPLIER CARLO HOUSE STREET ADDRESS, CITY. STATE, ZIP CODE 411 CARLO STREET SAN MARCOS, CA 92069 (X«)ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 1 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE W331 Continued From page 5 On 10/16/07, Client 1 was evaluated by^ physician as to the need for for sexuality and family life education. It was determined by the physician that Client 1 could benefit from a sexuality and family life training program. An interview was conducted with _ stae that d was not aware that Client 1's physician had recommended that this program be developed, Theljpl acknowledged that a sexuality and familylireprogram had not been developed and implemented for Client 1. 2. Client 2 was admitted to the facility on 10/25/02withdiagnosesthat included accordingotne ClientdentiTicOTonandtmergency Information sheet. Client 2's clinical record was reviewed on 2/28/08 at 8:10 A.M. According to the January 2008 monthly nursing summary report, the Registered Nurse (RN) had listed constipation, enuresis (bed wetting), dry skin, and cerumen (wax) in ears as identified health care issues for Client 2. However, these health care issues were not incorporated into Client 2's health care plan. There was no mention of these health care issues on Client 1's health care plan. An interview was conducted with the RN on 2/28/08 at 5:05 P.M. The RN acknowledged that the health care plans identified for Client 2 had not been incorporated intoH health care plan. No objectives or approachesnad been developed to address these health care issues. W331 FORM CMS-2667(02-99) Previous V«i*ton* Obsolete Event ID: DSMS11 Facility ID: CA090001018 If continuation sheet Page 6 of 11 DEPARTMENT OF HEALTH AND HUMA' CERVICES CENTERS FOR MEDICARE & MEDICAID oERVICES PRINTED: 03/05/2008 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER CARLO HOUSE (Xt)ID PREFIX TAG W331 (X1) PROVIDER/SUPPUER/CLIA (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: A. BUILDING 05G650 B.WING_ STREET ADDRESS, CITY, STATE, ZIP CODE 411 CARLO STREET SAN MARCOS, CA 92069 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 6 On 10/16/07, Client 2 was evaluated byB physician as to the need for for sexuality and family life education. It was determined by the physician that Client 2 could benefit from a sexuality and family life training program. An interview was conducted with theJHIH was not aware that Client Zspnysfcian had recommended that this program be developed. TheHpl acknowledged that a sexuality and fam il^ifeprogram dad not been developed and implemented for Client 2. 3. Client 3 was admitted to the facility on 1/28/90with diagnoses that IncludedJMMMMand ••••IClient Identification sheet. BBjj^BBJ ii i mliiii) In lln anoEmergency Information Client 3's clinical record was reviewed on 2/27/08 at 2:20 P.M. According to the January 2008 monthly nursing summary report, the Registered Nurse {RN) had listed acne and ear wax as identified health care issues for Client 3. However, these health care issues were not incorporated into Client 3's health care plan. There was no mention of these health care issues on Client 3's health care plan. An interview was conducted with the RN on 2/28/08 at 5:05 P.M. The RN acknowledged that the health care plans identified for Client 3 had not been incorporated intoH health care plan. No objectives or approachesnad been developed to address these health care issues. ID PREFIX TAG W331 (X3) DATE SURVEY COMPLETED 02/28/2008 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DSM511 Facility ID: CA090001019 If continuation sheet Page 7 of 11 ,PRINTED: 06/07/2007 APARTMENT OF HEALTH AND HU N SERVICES FORM APPROVED CENTERS FOR MEDICARE STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER CARLO HOUSE (X4)IO PREFIX TAG - W 124 & MEDICMiO SERVICES OMB NO. 0938-0391 (X1) PROVIOER/SUPPUER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY IDENTIFICATION NUMBER: A „„.,_,,_ COMPLETEDA. BUILDING 05G650 8WING-' " 04/27/2007 STREET ADDRESS, CITY, STATE, ZIP CODE 411 CARLO STREET SAN MARCOS, CA 92069 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 '•. Visitation, authorization to be taken from the facility for an outing or to visit the homes of people with the consent of the Administrator or their designee using private auto, an agency ! vehicle. i The Residential Director was interviewed on W183 4/27/07 at 3:00 P.M. ^jj acknowledged that the consents were overdue and that they required the signature of the clients' responsible party. 483.430(c)(2) FACILITY STAFFING There must be responsible direct care staff on duty and awake on a 24-hour basis, when clients are present, to take prompt, appropriate action In case of injury, illness, fire or other emergency, in each defined residential living unit housing: (i) Clients for whom a physician has ordered a medical care plan; (ii) Clients who are aggressive, assaultive or security risks; (iii) More than 16 clients; or (iv) Fewer than 16 clients within a multi-unit building. This STANDARD is not met as evidenced by; Based on interview and record review the facility failed to provide awake direct care staff (DCS) at night for clients with a record of being aggressive. Findings: On 4/24/07 at 5:00 P.M. the accident injury log was reviewed. The log indicated that a few of the clients (3, 4, 5 ,6) were documented as having aggressive behaviors. According to the house manager the behaviors were much improved over ID PREFIX TAG W124 W183 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Overnight staff are available to deal with any situation that may occur at night. If we need to supplement this staff and/or have an awake staff due to specific needs of an individual, we do so t 5 responsible for assess fing needs and ensuring . . opriate level of staff! |X5) COMPLETION DATC 5/27/07 ing ng. FORM CMS-2567(02-99) Previous Version* Obsolete Ev»ntlD:K£FV11 FaeWly ID; CA090001019 If continuation sheet Page 2 oM MRTMENT OF HEALTH AND HIT ' N SERVICES CENTERS FOR MEDICARE & MEDICftiJ SERVICES PRINTED: 05»T/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CL1A IDENTIFICATION NUMBER: D5G6SO (X2) MULTIPLE CONSTRUCTION A BUILDING B.W1NG. (X3) DATE SURVEY COMPLETED 04/27«007 NAME OF PROVIDER OR SUPPLIER CARLO HOUSE STREET ADDRESS, CITY. STATE, ZIP CODE 411 CARLO STREET SAN MARCOS, CA 92069 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE W 183 Continued From page 2 I last year because the client that aggitated the | other clients was no longer at the facility. | The DCS who worked the night shift was | interviewed on 4/24/07 at 9:00 P.M. • stated 1 thatH was allowed to sleep on the sola after the i clients went to bed. • said, " The clients are OK at night. I wake riqhFup when I hear Client 1 shuffle around. • usually has to get up and use the bathroom. I nelpH| to go back to bed when j§ is finished." The Director of Adult Services was interviewed on 4/24/07 at 9:15 P.M. • acknowledged the regulation that required DCS on duty and awake, on a 24 hour basis for aggressive clients. 483.470(h)(1) EMERGENCY PLAN AND PROCEDURES W438 The facility must develop and implement detailed j written plans and procedures to meet all potential emergencies and disasters such as fire, severe weather, and missing clients. This STANDARD is not met as evidenced by. Based on observation, interview and record review the facility failed to have an adequate amount of water supply to meet the needs of the clients and staff during an emergency. Findings: The emergency food and water supply was assessed on 4/25/07 at 9:00 A.M. The emergency water supply was observed in the garage supply pantry. The water packets were stored inside a duffle bag that was placed in a storage bin. There was a large amount of water W183 W438 damaged water packets e been replaced. >/27/07 responsible for ensuring 'adequate emergency supplies re available and in good condition. FORM CMS-2567<02-99) Previous Version* Obtotete Event ID: KEFV11 Facility ID: CA090001019 If continuation sheet Page 3 of 4 DEPARTMENT OF HEALTH AND HW vl SERVICES CENTERS FOR MEDICARE & MEDIC^ SERVICES PRINTED: 03/14/2006 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER CARLO HOUSE (X4) ID PREFIX TAG W120 (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: A. BUILDING 05G650 B.WING_ STREET ADDRESS. CfTY, STATE. ZIP CODE 411 CARLO STREET SAN MARCOS, CA 92069 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 who was standing against the dining room wall on the opposite side of the table. Client 2 then hit the HBI <>n II arms with I open hands. DCS 1 anoDCS ^immediately approached the client while calmly telling | escorted IB away room. j^ to stop and gently From the area to another Record review was conducted on 3/8/06. Client 2 was admitted to the facility on 1/28/93, with diagnoses including••••ifiL—--i^^^^^^^^l and^^^^^^^ccording to the record of admission. Client 2 was subsequently observed at the day program job site on 3/7/06, between 1 1 :20 A.M. and 1 1 :40 A.M. Client 2 was seated atH work station and engaged in a rest period between tasks. Client 2 talked about j| job and introduced H job coach. The job coach was interviewed at 11:30 A.M. The job coach was asked to explain hcw4B managed the client's aggressive/agitated behaviors at the job site. The job coach statedfl was unaware that Client 2 had these behaviors because the client did not exhibit any such behaviors when at work. The job coach was asked if (Phad copies of Client 2's assaultive behavior management program (ABMP). The job coach acknowledged that^ was not aware of and he did not have copies of the facility's ABMPs for Client 2. The job coach stated thatM was trained in PARTS (Professional Assault Response Training Strategies) and that based on this training he was prepared to intervene when any client exhibited behaviors. aggressive and or agitated ID PREFIX TAG W120 (X3) DATE SURVEY COMPLETED 03/08/2006 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) <X5) COMPLETION DATE FORM CMS-2567(02-99) Previous Vsrstons Obsolete Event ID: JLNP11 Facility ID: CA090001019 If continuation sheet Page 2 of 23 DEPARTMENT OF HEALTH AND HUr- N SERVICES CENTERS FOR MEDICARE & MEDIC/.. J SERVICES PRINTED: 03/14/2006 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER CARLO HOUSE (X4) ID PREFIX TAG W120 W124 (X1) PROVIDER/SUPPLIER/CUA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY IDENTIFICATION NUMBER: COMPLETEDA BUILDING 05G650 BWINQ 03/011/2006 STREET ADDRESS, CITY, STATE, ZIP CODE 411 CARLO STREET SAN MARCOS, CA 92069 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 On 3/08/06 at 1 1:10 AM., the QMRP was interviewed. The! unaware that the p •| acknowledged m was pcoach did not have copies of Client 2's ABSPs. ThelHHj did not know when or if the job coach receivedinstruction in the specific behavioral intervention techniques (ABIT) included in the facility's ABMPs for Client 2. jjj^ acknowledged that the job coach should be knowledgeable about the client's history of aggressive/agitated behaviors and thatd should have copies of the ABMP with m at the job site. 483.420(a)(2) PROTECTION OF CLIENTS RIGHTS The facility must ensure the rights of all clients. Therefore the facility must inform each client, parent (if the client is a minor), or legal guardian, of the client's medical condition, developmental and behavioral status, attendant risks of treatment, and of the right to refuse treatment This STANDARD is not met as evidenced by: Based on interview and record review, the facility failed to ensure that informed consents were obtained for the restrictive interventions incorporated into 2of 3 (2,3) sampled clients adaptive behavioral support plans (ABSP). In addition, informed consent was not obtained for the administration of a pre-sedation medication, to 1 of 3 (3) sampled clients. Findings: 1. Client 2's record was reviewed on 3/08/06. Client 2 was admitted to thefacilityonl/23/93. withdiagnoses includingHH^^^HH •™"and" ^JJUJ nliini liilln ID PRERX TAG W120 W124 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Consents will be obtained for restrictive hands on behavioral interventions. These are currently reviewe at Human Rights meetings. ••Jl responsible for oDtaining consents as neces Consents will be obtained by the RN prior to use of pre-sedation medication. <X5) COMPLETION DATE ^/8/06 i 3ary . FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JLNP11 Facility ID: CA090001019 If continuation sheet Page 3 of 23 DEPARTMENT OF HEALTH AND HIT N SERVICES CENTERS FOR MEDICARE & MEDIC/Mi) SERVICES PRINTED: 03/14/2006 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PtAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER CARLO HOUSE (XI) ID PREFIX TAG W124 (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER:A BUILDING 050650 8WlNG STREET ADDRESS, CITY, STATE, ZIP CODE 411 CARLO STREET SAN MARCOS, CA 92069 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEOED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 record of admission. Review of the annual individual service plan dated 4/18/05, revealed written program objectives for client behaviors identified as tantrum build-up and tantrums/aggression. Interventions in the adaptive behavior support plan included the administration of as needed medication, and the use of ABIT (assaultive behavioral intervention training) techniques. Some of the techniques included in the ABIT manual involved "hands on" interventions such as physical escort and containment. Further record review revealed that informed consents were obtained for the use of psychotropic medication used to manage the client's behavior. However, informed consent was not obtained for the use of the restrictive hands on interventions included in the ABIT techniques in the ABMP. On 3/08/06 at 1:00 P.M.. the^^MMBI •••••ZZ^ ^H and the Director of Residential Services, acknowledged that informed consents were not obtained for the use of the restrictive hands on interventions included in the ABIT techniques in the ABMP. 2. The client's record was reviewed on 3/08/06. Client 3 was admitted to thefacilityonl/26/93, wfthdiagnoses including||^HHHMH accoralngi to the reSrdoTsramissior^Review of the annual individual service plan dated 9/26/05, revealed written program objectives for client behaviors identified as extreme tantrum build-up and tantrums. ID PREFIX TAG W124 (X3) DATE SURVEY COMPLETED 03/08/2006 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) <X5) COMPLETION DATE FORM CMS-2567(02-99) Previous Verttons Obsolete Event ID: JLNP11 Facility ID: CA090001019 If continuation sheet Page 4 of 23 DEPARTMENT OF HEALTH AND HUM/! "SERVICES CENTERS FOR MEDICARE & MEDICAti oERVICES PRINTED: 05O1/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A BUILDING 05G082 BWING 05/2:J/2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1736 ANZAANZA HOUSE IMOAN^A VISTA, CA 92083 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX : (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG : REGULATORY OR LSC IDENTIFYING INFORMATION) W 000 ; INITIAL COMMENTS The following reflects the findings of the Department of Health Services during a FUNDAMENTAL Survey. ID PREFIX TAG WOOD i Representing the Department of Health Services: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) R 1 G E 1 ¥ E rj\< [~n IU 1] ,!UN 6 2007 \VJ Nanette Moore. HFEN ! <-"" i The census of the facility during the survey was 6 < clients. The sample size was 3 clients. W 183 | 483.430(c)(2) FACILITY STAFFING There must be responsible direct care staff on duty and awake on a 24-hour basis, when clients are present, to take prompt, appropriate action in case of injury, illness, fire or other emergency, in I each defined residential living unit housing: I (i) Clients for whom a physician has ordered a medical care plan; ', (ii) Clients who are aggressive, assaultive or security risks; j (iii) More than 16 clients; or : (iv) Fewer than 16 clients within a multi-unit ; building. [ This STANDARD is not met as evidenced by: W183 ! Based on observation, interview and record i review, the facility failed to provide awake overnight staff, for 3 of 3 sampled clients (2, 5, 6), and 3 clients added to the sample (1, 3, 4). Findings: ; On 5/21/07 at 5:05 A.M., the surveyor arrived at ! the facility, rang the doorbell and knocked on the door with no answer. At 5:20 A.M., a Direct Care Staff (DCS) opened the door in her night gown. She stated she lived in the house and that her LICENSING AND CERTIFICATION SAN DIEGO DISTRICT OFFICE SOUTH A . -r L. g^M-Qjce, flOftAJok fe deed W\tt\cwu i S\Tfl^i"Wv\ ~V»1&J^ ^Vi&M GCOKf\ Tf i f 1~ '/ U \AS ! '\i\C- lfYRl^U*£>~nvo D6KKX-vl(X3 u • \ ' L\f\ ivUt> *^U»S£- Owe- W\"TVc^jU1 OOhC^ dowt <?£u*t '^w\\ft\ •\ IP YV^^f TZ? ^G^p Itx'A'&t/i"* ,, , , ,*- . i TVIC: ^V^^\XMV\t ^TTttrv C^\c\i . J j \ rr \*Yrt£-0(A Au^u6c^"Wt Cw*> i ./-. t A£/> V-A ''T^^d&O\C\C\\tf\(MW; |VM^ 0 F)lsT JUir />£ ^^f(f\(^ /\ WvC! Jl/l'l56?TZ?' C/l Iv?-9 tiAOvk \{*\s\ £W\)\.(jL<<i ^^>0^fX\f) \£ ~Q>Ty^. (X5) COMPLETION DATE ^JH/^ i &f3 OS LABORATORY-DIRECTOR'S 0R PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may pi excused from correcting providing it is determined that" other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing"nomes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MJK11 Facility ID: CA090000120 If continuation sheet Page 1 of 4 DEPARTMENT OF HEALTH AND HUM SERVICES CENTERS FOR MEDICARE & MEDICAlu SERVICES PRINTED: 05/31/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 05G082 (X2) MULTIPLE CONSTRUCTION A. BUILDING BWING (X3) DATE SURVEY COMPLETED 05/23/2007 NAME OF PROVIDER OR SUPPLIER ANZA HOUSE STREET ADDRESS, CITY, STATE, ZIP CODE VISTA, CA 92083 (X4) ID I SUMMARY STATEMENT OF DEFICIENCIES PREFIX i (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG i REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE W 183 Continued From page 1 shift would start at 6:30 A.M. She stated that she i worked in the facility with another staff from 6:30 | A.M. to 9:00 A.M. and 3:30 P.M. to 9:00 P.M. I She stated she was alone with the clients from I 9:00 P.M. to 6:30 A.M. She also stated that she slept during the night and that the clients would wake her up if they needed help. Entrance to the staff quarters was on the main floor of the house. A second story was erected ; over the staff quarters. According to the DCS, J she slept upstairs but would leave the door open ; so she would hear the clients if they needed help. ; Client records were reviewed on 5/23/07 and ! revealed that all clients in the facility had behavior 1 programs for maladaptive behaviors. : The acting Qualified Mental Retardation : Professional (QMRP) was interviewed on 5/21/07 at 7:20 A.M. She acknowledged the facility did • not have an awake staff on a 24-hour basis. She stated that the DCS, who lived in the house, would assist the clients at night if help was needed. W 261 i 483.440(f)(3) PROGRAM MONITORING & |CHANGE j The facility must designate and use a specially ' constituted committee or committees consisting i of members of facility staff, parents, legal ; guardians, clients (as appropriate), qualified persons who have either experience or training in contemporary practices to change inappropriate client behavior, and persons with no ownership or controlling interest in the facility. i This STANDARD is not met as evidenced by: W 183 W261 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MJK11 Facility ID: CA090000120 If continuation sheet Page 2 of 4 DEPARTMENT OF HEALTH Ah UMAN SERVICES CENTERS FOR MEDICARE & McuHCAID SERVICES Printed 03/30/2006 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER ANZA HOUSE (X4) ID PREFIX TAG W312 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 05G082 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 03/28/2006 STREET ADDRESS, CITY. STATE. ZIP CODE 1736 ANZA VISTA, CA 92083 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 8 According to the behavior plan, implemented 04/96 and revised 02/03, one targeted behavior was identified as, "Tantrums to include: self-abuse resulting in injury, kicking, spitting, scratching, pulling hair, slapping self or others, and biting self or others." A second behavior plan, dated 4/04/96 targeted behaviors and revised 02/03, indicated of, "Tantrum build-up to include: Increased perseverative speech. increased repeating of "Kenny Rogers," crying, picking atfll fingers, pulling own hair, rubbing wrists as though wringing of hands. Body shaking, eyes will get very large, racial expression will change to somber and become very flushed. Ignoring staff requests or presence." According to the physician's orders, dated ID PREFIX TAG W312 4/04/96Jh^ientwasprescritedl^ji^« HHJj The behavior plans did not include the behaviors. The acting MBBIipapHL m^Jtilized to control the •••^^ I • was interviewed on 3/28/06, at 4:45 P.M. She acknowledged the ^^HH medications utilized to control the client's behaviors were not management plan. integrated into the behavior 1 b. According to dental records, the client routinely required the use of general anesthesia for dental procedures. On 1/07/04, the dentist indicated the client displayed "Management Difficulty," which required the use Of general anesthesia. The behavior plans did not include the routine use of general anesthesia utilized to control the behaviors. PROVIDER'S PLAN OF CORRECTION ! («) (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE FORM CMS-2567(02-99) Previous Versions Obsolete G2HE11 If continuation sheet Page 9 of 18 DEPARTMENT OF HEALTH AN UMAN SERVICES CENTERS FOR MEDICARE & MtJlCAID SERVICES Printed: 03/30/2006 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPUER/CLIA IDENTIFICATION NUMBER: 05G082 (X2) MULTIPLE CONSTRUCTION A BUILDING B. WING (X3) DATE SURVEY COMPLETED 03/28/2006 NAME OF PROVIDER OR SUPPLIER ANZA HOUSE STREET ADDRESS, CITY, STATE, ZIP CODE 1736 ANZA VISTA, CA 92083 (X4)ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETION DATE W312 Continued From page 9 The acting JP8 was interviewed on 3/28/06 at 4:45 P.M. Instated 0 was not aware pB needed to incorporate the routine use of general 2a. Client 2's medical record was reviewed on 3/28/06. The client was admitted to thefacility on 3/16/98, with diagnoses that i |, according to the face sheet. According to the behavior plan, dated 06/17/98 and revised 02/00. the targeted behavior was, "Verbal outbursts to include screaming, shouting, and being rude." A second behavior plan, dated 07/98 and revised 05/01, indicated the targeted behavior was, " Tantrum Build-up to include 2 or more of the following: being rude (bumping into people, calling names), repeated verbal outbursts, ignoring staff, increased agitation (heavy breathing, body tension, angry facial expression, grinding teeth) talking about being tired, saying that0B does n 'Heel good, whining, saying "I'm going to tell myjfffto get me out of this place," talking about family, complaining of medical problems; repeated tying shoes." According to the physician's order, datedl/11/pl, the client was prescribed Risperdal for^^mH In addition, on 2/10/00, the client was prescribed ^ did not s tne^^^HH^^^^Hutilized to control the The actin _ _____^__^ _ was interviewed on 3/28/06, at 4:45 FTMT(packnowledged the _ medications utilized to control the client's behaviors were not integrated into the ilan. W312 FORM CMS-2 567(02-99) Previous Versions Obsolete G2HE11 If continuation sheet Page lOoMB DEPARTMENT OF HEALTH AND HU,«MN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Printed: 02/01/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROV1DER/SUPPLIER/CLIA IDENTIFICATION NUMBER' 05G170 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 01/18/2007 NAME OF PROVIDER OR SUPPLIER GRACE HOUSE STREET ADDRESS, CITY, STATE, ZIP CODE 2507 HIBISCUS AVENUE VISTA, CA 92083 (XI) ID SUMMARY STATEMENT OF DEFICIENCIES ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETION DATE W183 Continued From page 10 statedB| got up at 10:00 P.M. and 2:00 A.M. to toileted three of the clients. | was interviewed on 1/16/07 at 6:30 P.M. [stated that Client 3 frequently displayed maladaptive behaviors, which required staff interventions. ^| attributed the increase in behaviors to multiple changes in the clients caregivers. 4. Client 4 was observed on 1/16/07 between 3:40 P'.M. and 9:00 P.M. and on 1/17/07 between 6:05 A.M. and 8:45 A.M. The client was sight impaired and required stand-by assistance of the staff to ambulate. The client required verbal prompts and physical assistance with activities of daily living. The client wore a soft leather helmet, which was only removed when the client was showered. The client repeatedly hit the right side ofBPhead with a closed Fist, which required redirection by the staff. Client 4's medical record was reviewed on M O/Q7 Tho /^lionf W183 • according to the clienTraerumcation and emergency information form. According to the adaptive behavior support plan, dated October 2006, the client was assessed with, "Severe head banging: forcefully and repetitively hitting head with hands and/or head banging on wall or floor" Direct Care Staff (DCS) 1 was interviewed on 1/16/07 at 6:30 P.M. || statedMslept in a second floor bedroom wlthH^^^|H fr°m 9:00 P.M. until 6:00 A.M., Whiletheclients slept on the main level of the house. H stated \^ turned on a baby monitor during the night. FORM CMS-2567(02-99) Previous Versions Obsolete ZLL411 If continuation sheet Page 11 of 30 DEPARTMENT OF HEALTH AND ;MAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 04/21/2008 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING 05G080 BWING- COMPLETED 04/1'1/2008 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE MONTGOMERY HOUSE IS JTSST "*VISTA, CA 92083 (X4) ID PREFIX TAG WOOO W125 tXSSHW SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) - INITIAL COMMENTS The following reflects the findings of the California Department of Public Health during a FUNDAMENTAL survey. Representing the Department of Public Health: Aty Knooren.HFEN. The census of the facility during the survey was 6 clients. The sample size was 3 clients. 483.420(a)(3) PROTECTION OF CLIENTS RIGHTS The facility must ensure the rights of all clients. Therefore, the facility must allow and encourage individual clients to exercise their rights as clients of the facility, and as citizens of the United States, including the right to file complaints, and the right to due process. This STANDARD is not met as evidenced by: Based on interview and record review the facility failed to ensure that an informed consent was obtained for "Cleaning supplies locked up" for 1 of S samnled client"; (?} Findinas'WQIIIf/IWVdl WIIWII1& \Sfft 1 IIIWlll^W. According to the client's face sheet, Client 2 was admitted to thefadlityon1/12^4withdiagnoses that includedHMMMH Record review on 4/10/08 at 11 :00 A.M. indicated that the consent for locking up cleaning supplies was not signed by the client's conservator. Ti>eH|MHHH|HMM_II^H^wa^rrterviewec^nnanime^TnejHJI stateatriat the consent was sent to the conservator on 1/29/08and it had not been ID PREFIX TAG WOOO W125 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) The facility shall ensure the rights of alldtents. 1rte^H has received consent from client 2's conservator for locking up cleaning supplies. The ••shall ensure that this regulation continues to be met by Internal auditing of client records. Q) Puu u I MAY 2 2008 {Jj ^ ^&—~r) /(e,/@J^ ? UCfNSiNCANDfrtftrirtannN SAN niFGo DisiRicToFFicTsoufH \HD? 1TO t vlOL^^ <X5) COMPLETION DATE 4/11/08 TrLf\ (a < »J\ i WDATE O&Wt^ 4t!dC6 Any deficiency statement ending with ah asterisk f) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the pattents. (See Instructions.) Except for flurslr>g homes, the findings stated above are dl3closat>te 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disposable 14 days fallowing the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction Is requisite to continued program participation. FORM CMS-2667(02-99) Previous Versions Obsolete Event ID: M2XX11 Facility ID: CA090000745 if continuation sheet Page 1 of 4 DEPARTMENT OF HEALTH ANL JMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 04/21/2008 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CUA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER. COMPLETEDA. BUILDING 05G080 B'WING-04/11 /2008 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE. ZIP CODE MONTGOMERY HOUSE .^l^0!!'!00!'"^ °R VISTA, CA 92083 (X4) ID PREFIX TAG W125 W249 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 retuned. •• acknowledged that there was no consent fonocking up the cleaning supplies. 483.440{d)(1) PROGRAM IMPLEMENTATION As soon as the interdisciplinary team has formulated a client's individual program plan, each client must receive a continuous active treatment program consisting of needed interventions and services in sufficient number and frequency to support the achievement of the objectives identified in the individual program plan. This STANDARD is not met as evidenced by: Based on observation, interview and record review the facility failed to implement the program as written for 1 of 3 sampled clients (1). As a result the client did not participate in a board game with a peer for over a month. Findings: On 4/8/08 in the late afternoon, Client 1 was observed coloring in the kitchen, with two other clients at the table. After dinner, the client was observed coloring at the dining room table. Record review was conducted on 4/10/08 at 9:00 A.M. The Individual Service Plan (ISP) dated 9/1 1/07 indicated that Client 2 had a leisure skill program for playing a board game with a peer. Review of the data collection indicated that in March, '08 out of 31 days, the client did a puzzle 9 days and did coloring the other 22 days. In April, '08 out of 9 days, the client colored all of the 9 days. ID PREFIX TAG W125 W249 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) As soon as the Interdisciplinary team has formulated a client's Individual program plan, each dient shall receive a continuous active treatment program consisting of needed interventions and services in sufficient number and frequency to support the achievement of the objectives identified In the individual program plan. The staff has been trained on Client 1's leisure program for playing a board game with a peer. The||| shall ensure that this regulation continues to be met by routine observation and monitoring of the data collected. (X5) COMPLETION DATE 4/11/08 FORM CMS-2667(02-89) Previous Versions Obsolete Event ID; M2XX11 Fadllly ID: CA090000745 If continuation sheet Page 2 of 4 DEPARTMENT OF HEALTH ANL Jto. .;< SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 04/21/2008 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 05G080 (X2) MULTIPLE CONSTRUCTION A. BUILDING BWING (X3) DATE SURVEY COMPLETED 04/11/2008 NAME OF PROVIDER OR SUPPLIER MONTGOMERY HOUSE STREET ADDRESS, CITY, STATE, ZIP CODE 1658 MONTGOMERY DR VISTA, CA 92083 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5> COMPLETION DATE W249 W478 Continued From page 2 acknowledged that the staff were not implementing the program as it was written. 483.480(c)(1)(ii) MENUS Menus must provide a variety of foods at each meal. This STANDARD is not met as evidenced by: Based on observation, interview and record review the facility failed to serve the variety of foods as written on the evening dinner menu. Findings: The clients were observed eating their dinner on 4/08/08 at 6:00 P.M. The clients were all eating a pork chop, cooked with BBQ sauce, 1/2 cup green beans, 1 cup fruit salad, a com muffin and 8 oz. water to drink. Review of the posted dinner menu for 4/8708 indicated all of the above food items and in addition, 1 cup of BBQ beans was on the menu. Record review on 4/10/08 indicated that 2 of 3 sampled clients (2,3) were on a care plan/medications for the prevention of constipation. The omission of 1 cup of BBQ beans had the potential of decreasing the amount of available dietary fiber for the clients. The house manager (HM) was interviewed at the end of the meal about the lack of BBQ beans for dinner. l| stated thatHjj read the menu incorrectly and when^Bsaw "BBQ" thought it said BBQ pork chop ana forgot about the BBQ baked beans. W249 W478 The facility shall provide avanety of foods at each meal. TheH|||has provided staff with retraintngon reading the menu properly and has counseled staff on ensuring that all menu items are served or appropriate substitutions are made for each meal. ThepU snaH ensure that this regulation continues to be met by routine observation and internal quality assurance auditing. 4/11/08 FORM CMS-2567(02-W) Previous Versions Obsolete Event ID: M2XX11 Facility ID: CA09000074S If continuation sheet Page 3 of 4 DEPARTMENT OF HEALTH AND MAN 6ERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 04/21/2008 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PUN OF CORRECTION NAME OF PROVIDER OR SUPPLIER MONTGOMERY HOUSE (X4) 10 PREFIX TAG W478 (X1) PROVIDER/SUPPLIER/CLJA (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER:A. BUILDING 05G080 BWING- STREET ADDRESS. CITY. STATE, ZIP CODE 1658 MONTGOMERY DR VISTA, CA 92083 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 9was interviewed after the meal andfll edged that the variety of food as specified on the menu was not provided at dinner, ID PREFIX TAG W478 (X3) DATE SURVEY COMPLETED 04/11/2008 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (xs) COMPLETION DATE FORM CMS-2W7(02-») Previous Vontons Obsolete Event ID: M2XX11 Facility ID: CA080000745 If continuation sheet Page 4 of 4 California Department of Public Health PRINTED: 03/06/2008 FORM .APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETEDA. BUILDING B. WINGCA090000745 03/06/2008 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MONTGOMERY HOUSE 1 658 MONTGOMERY DR VISTA, CA 92083 (X4) ID PREFIX TAG BOOO Cl/r SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Initial Comments The following reflects the findings of the California Department of Health Services during the investigation of one (1) complaint. Complaint number: CA001 39347 Representing the Department: Aty Knooren, HFEN. The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. No deficiencies were issued for complaint number: CA001 39347 ID PREFIX TAG BOOO PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ""¥ TjTO lIlinfflr^SiSTy^Utd JHtoU %MfQJ ^TlCkT""1 STATE FORM Z2CI11 If continuation sheet 1 of 1 California Department of Public Health PRINTED: 03/06/2008 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING B. WINGCA090000745 03/06/2008 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MONTGOMERY HOUSE 1658 MONTGOMERY DR VISTA, CA 92083 (X4) ID PREFIX TAG BOOO tABORATOJ SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Initial Comments The following reflects the findings of the California Department of Health Services during the investigation of one (1) complaint. Complaint number: CA00139368 Representing the Department: Aty Knooren, HFEN. The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. No deficiencies were issued for complaint number: CA001 39368 V ID PREFIX TAG BOOO PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ^BtftEOTOfljS Ofr IRC i/IDER/SjJlBmgR«EPR6^TATIVgg^TGNA URE TITLED * i (X6JDATE STATE FORM If continuation sheet 1 of 1 DEPARTMENT OF HEALTH AND K f" SERVICES CENTERS FOR MEDICARE & MEDICAIl CERVICES PRINTED: 06/21/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER 05G080 (X2) MULTIPLE CONSTRUCTION A BUILDING 8 WING (X3) DATE SURVEY COMPLETED 06/08/2007 NAME OF PROVIDER OR SUPPLIER MONTGOMERY HOUSE STREET ADDRESS, CITY, STATE, ZIP CODE 1658 MONTGOMERY DR VISTA, GA S20a3 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES | ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL i PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION) , TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE WOOD INITIAL COMMENTS The following reflects the findings of the California • Department of Health Services during a FUNDAMENTAL survey. Representing the Department of Health Services: Christine Reed, HFEN The census of the facility during the survey was 6 , clients The sample size was 3 clients W 113 483.410(c)(3) CLIENT RECORDS The facility must develop and implement policies and procedures governing the release of any client information, including consents necessary '. from the client, or parents (if the client is a minor) or legal guardian. i This STANDARD is not met as evidenced by: Based on interview and record review the facility failed to ensure that informed consent for medical, surgical, and dental treatment were obtained in a timely manner for 2 of 3 sampled clients (1, 3). Findings 1. Client 1 was admitted ft? the facility on 12/26/31 with a diagnosis of| according to the Cffeni tdentttteatton anc Emergency Information sheet. A review of Client 1's clinical record was conducted on 6/08/07 at 10' 15 A M Client 1 's consent for medicaJ, surgical, and dental treatment was blank. There was no signature present from a parent or legal guardian. A notation on the consent indicated that the consent had been "sent 4/30/07." W 000 W 113 Signed consents have been '.received for these individu JQMRP is responsible for job tain ing and filing (signed consents.i 7/z.o/o •? i'/a/o? ils. LABORATORY BfRECTOR'S OS'PROVtDEWSUPPueR REPfiifeiNtATiVE'g S16NATURE TITLE Director of Adult Services 7/12/07 iy deficiency statement ending with an asterisk (*) denotes a deficiency which ths institution may be excused from cocreeting providing it is determined thai ier safeguards provide sufficient protection to the paftenlfe. (SeejnStrUgli&ns^^Exge^Jgf jTursjfja^homjss^ihja r]ndjrj§5^iate^_above are disclqsatite 90 days "~ owing (tie dafe~6f survey vvhether^rTwt a plan of eorre^tion is provided. For nursing home*, the abdve findings and plans of correction are disclossbla 14 s following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued ram participation CMS-2567(02-99) Previous Versions Obsolete Event ID G8D511 Facility ID CA090000745 I continuation sheet Page 1 o(12 DEPARTMENT OF HEALTH AND Hu,^' "ERVICES CENTERS FOR MEDICARE & MEDICAIL CERVICES PRINTED: 06/21/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION <X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 0§G080 (X2) MULTIPLE CONSTRUCTION A BUILDING 6 WING (X3) DATE SURVEY COMPLETED 06/08/2007 NAME OF PROVIDER OR SUPPLIER MONTGOMERY HOUSE STREET ADDRESS. CITY, STATE, ZIP CODE 1658 MONTGOMERY DR VISTA, CA 92083 <X4)ID SUMMARY STATEMENT OF DEFICIENCIES ' ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL ' PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION) ' TAG PROVIDER'S PLAN ©F CORRECTION (EACH CORRECTIVE ACTION SHOULD BE GROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) <X5) COMPLETION OATE W 113 Continued From page 1 During an interview with ^^^^ ..^^^_ *mmmmm ^^^^\ on h/nil/il/ ,il III ,"i AM Ihi'gMJj'iilcil llul the consent had been mailed 16 Ctierit 1 's mother on 4/30/07 and the mother had not yet returned the consent. The|m acknowledged that there was no valid consent for medical, surgical, or dental treatment for Client 1. 2 Client 3 was admitted to trje facilit with diagnoses cm 1 1/Q1/89 > and W 183 Identification and Emergency Information sheet. A review of Client 2's clinical record was conducted on 6/08/07 at 8:30 A.M. Client 2's consent for medical, surgical, and dental treatment was blank. There was no signature present from a parent or legal guardian. A notation on the consent indicated that the consent had been "sent 4/30/07 " i an interview \ Jon — ia*tneconsent had been mailed to Client 2's parents on 4/30/07 and thepajgUs had not yet returned the consent. The J((B acknowledged that there was no valid corrsefitlor medfeal, surgical, or dental treatment for Clients. 483.430(e)(2) FACILITY STAFFIN© There must be responsible direct care staff on duty and awake on a 24-hour baste, when clients are present, to take prompt appropriate action in case of injury, illness, fire or other emergency, in each defined residential living unit housing: (i) Clients for whom a physician has ordered a medical care plan; (ii) Clients who ate aggressive, assaultive or w 113; w IBS;,Overnight staff are available to deal with any situation that may occur at night. If we need to supplement this 7/8/07 FORM CMS-256r(02-99) Previous Versions Obsolete EvenllD'G8D"S11 FaoilKylD CA090000745 If continuation sheet Page 2 of .12 DEPARTMENT OF HEALTH AND HUM/ SERVICES CENTERS FOR MEDICARE & MEDICAIU SERVICES PRINTED: 06/21/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPUERyCLIA IDENTIFICATION NUMBER 05G080 (X2) MULTIPLE CONSTRUCTION A BUILDING B WING (X3) DATE SURVEY COMPLETED Q6/08/2007 NAME OF PROVIDER OR SUPPLIER MONTGOMERY HOUSE STREET ADDRESS, CITY. STATE, ZIP CODE 1658 MONTGOMERY OR VISTA, CA 92083 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD 8E CROSS-REFERENCED TO THE APPROPRIATEDEFICIENCY) COMPLETION W 183 Continued From page 2 security risks, (iii) More than 16 clients; or (iv) Fewer than 16 clients within a multi-unit building. This STANDARD is not met as evidenced by: Based on observation, interview, and record review the facility failed to provide awake overnight staff for 1 of 3 sampled clients(2) who had a history of aggressive and assaultive behavior and of being a security risk. W183 staff and/or have an Awake Overnight staff due to specific needs of an individual, we do so. The Hm ls also available as a back-up. ensuring to meet the is responsible for; appropriate staffing needs of client* Findings' Client 2 was admitted to the with diagnoses ¥30/82 withdiagno H1HHto the Cliento the Client Identification arid Emergency Information sheet Client 2's clinical record at|| day program was reviewed on 8/07/07. There was an alert on Client 2's day program record that indicated Client 2 had a "habit of wandering in the house at nigftt, usually to use J§ activities, access the bathroom, or check on staff, |lwill occasionally open the front door or the friftcn doors by the dining area. On two occasions has left the facility during the night and wandering.. " tn order to protect Client 2. the staff are to "1 . use the door alarm security system during the day and at night. 2 at night, turn on the security bearn tn the dining area when Client 2 goes to bed. ." The incident and accident log for the group home was reviewed on 6/06/07 at 8:30 A.M. A review of the log for the past 12 months revealed that Client 2 displayed the following behaviors: FORM CMS-2S67(02-99) Previous Versions Obsolete Evert ID G8D511 Facility ID CA090000745 If continuation sheet Page 3 of 12 DEPARTMENT OF HEALTH AND HL,,.A" CERVICES CENTERS FOR MEDICARE & MEDICAIL CERVICES PRINTED: 06/21/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIBER/SUPPLIER/CLIA IDENTIFICATION NUMBER 05G080 (X2) MULTIPLE CONSTRUCTION A BUILDING B WING CO) DATE SURVEY COMPLETED 06/08/2007 NAME OF PROVIDER OR SUPPLIER MONTGOMERY HOUSE STRE£tADDR€SS, CITY. STATE. ZIP CODE 1658 MONTGOMERY DR VISTA, CA 92Q83 (X4»ID SUMMARY STATEMENT QF DEFICIENCIES ID ; PREFIX (EACH DEFICIENCY MUST BE PRECEDED 8Y FULL PREFIX I TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG i PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-RiFERENCED TO THE APPROPRIATE DEFICIENCY) |XS) COMPLETION DATE W 183 Continued From page 3 6/25/0© - hit window and cut palm of hand 7/09/06 - behavior tantrum 8/16/06 - grabbed another client in the van 9/20/06 - bit another client on the shoulder 10/08/06 -agitated behavior / throwing furniture 10/29/06-agitated behavior 3/06/07 - agitated behavior / property destruction 3/08/07 - hitting and pushing other clients 3/08/07 - self injurious behavior / property damage 3/12/0? - agitated behavior / property destruction • 3/14/07 - pushed roommate off of bed I 4/08/07 - aggressive behavior 4/16/07 - seratchedM face and ripped clothes off 4/20/07 - agitated behavior 4/22/07 - aggressive behavior / attempting to hit other clients The incident report for the self injurious behavior and property damage that occurred on 3/08/07 documented the length of the incident as being < "on and off most of night -12:45 A tiil 6:30 A," Ctteht 2's current behavior plan documented a p^st history of "Elopement and ftifhttirtve behaviors1' The history tfi the behavior plan stated that Client 2 "w«fjls te know who is working at night at the house, jjjl has a history of trying to leave the house te fincthe live-in in their apartment, or to s«« i f they are home. Sometimes^ will not 90 to sleep unless(| sees that they are okaf and there." A review of Client 2's group home cliflteat record was conducted on 6/OS/07 at 12:45 P.M. The ; physician orders revealed that Client 2 had an i order ^or^jjjjfi 5 mg. (milligram) by mouth every 2 hourOFneedeei for agitation. W183; FORM CMS-2567(02-99) Previous Versions Obsolete gve«l)0 G8OSV1 Facility ID 0*098090745 If eofitirwatton shee* Page 4o(12 DEPARTMENT OF HEALTH AND Hb.vi/>' CERVICES CENTERS FOR MEDICARE & MEDICAIL CERVICES PRINTED: 06/21/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 05G080 (X2) MULTIPLE CONSTRUCTION A BUILDING 8 WING (X3) DATE SURVEY COMPLETED 06/08/2007 NAME OF PROVIDER OR SUPPLIER MONTGOMERY HOUSE STREET ADDRESS. CITY. STATE ZIP CODE 1658 MONTGOMERY OR VISTA, CA 92083 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES [D PREFIX (EACH DEFICIENCY MUST 8E PRECEDED BY FULL PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG PROVIDER'S PLAN OF CORRECTION | (XS) (EACH CORRECTIVE ACTION SHOULD BE j COMPLETION CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) W 183 Continued From page 4 On 6/06/07, at 5:25 A!M. the surveyor arrived at the facility to begin the annual recertification survey. The surveyor knocked on the door three separate times. The door was answered after \ knocking the third time by Direct Care Staff (DCS)! 1. DCS 1 was dressed in pajamas and asked the • surveyor to wait in the living room whileBJ got jj§ bathrobe When DCS 1 returned •fstated that (j worked until 9:00 P.M. at nignWnd that (d goes to sleeP at 11:0° P-M ^^ 1 further stated that there were 2 clients that were bed wetters that DCS 1 had to get changed and toileted during the night. DCS 's bed was located in a room off of the dining room which was between the kitchen and the living room The requirement for awake overnight staff when there is a client in the facility that display aggressive and assaultive behavior and is a seeurfty risk was discussed with t during an interview on 6/06/07 at W 352 483.460{f)i(2) COMPREHENSIVE DENTAL DIAGNOSTIC SERVICE Comprehensive dental diagnostic services include periodic examination and diagnosis performed at least annually. This STANDARD is not met as evidenced by: Based on interview and record review, the facility failed to ensure that 3 of 3 sampled efients (1,2, 3) had annual dental examinations. Findings 1. Client 1 was admitted to the facility on 12/26/81 a diagnosis of I W 183 W352J 7/8/07 facility R.N.works •closely with the dentist |to facilitate timely dentalj icare for clients. Due to ;the lengthy process required jto get approval for dental 'treatment, the limited .availibility of dentists FORM CMS-25$7(02-99) Previous Versions OBsotele Event ID G8D511 Fac*lY ID CA090000745 If continuation sheet Page 5 of 12 DEPARTMENT OF HEALTH AND Hu-.A" CERVICES CENTERS FOR MEDICARE & MEDICAIL oERVICES PRINTED: 06/21/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 05G080 (X2.) MULTIPLE CONSTRUCTION #. BUILDING B WING (X3) DATE SURVEY COMPLETED 06/08/2007 NAME OF PROVIDER OR SUPPLIER MONTGOMERY HOUSE STREET ADDRESS. CITY. STATE, ZIP CODE 16S8 MONTGOMERY DR VISTA, CA 92083 (X4)ID SUMMARY STATEMENT OF DEFICIENCIES ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PRE'FIX TAB REGULATORY OR LSC IDENTIFYING INFORMATION) TAG PROVIDER'S PLAN OF CORRECTION ' (X5) (EACH CORRECTIVE ACT ION SHOULD BE i COMPLETION CROSS-REFERENCEB TO THE APPROPRIATE DATE DEFICIENCY} W 352 Continued From page 5 according to the Client Identification and Emergency Information sheet. Client 1's clinical record was reviewed on 6/08/07 at 10:15 A.M. The last documented dental examination for Client 1 was dated 3/QT/pg. PuTlng afl interview with the Acjir acknowledged that the client's dentist was trying to catch up on all of the dental examinations 2 Client 2 was admitted to thefaili /30/a2 2's clinical record wgs reviewed ori 6:/Qi/D7 at 12:45 P.M, The last documented dental examination for Client 2 was A.M., that the client's dentist was trying to catch up on afl of the dental examinations 3 Client 3 was admitted to the facility i 11/01 /89 w4th diagnoses ' [andl it rs elrffeti f eeorfl was 7 at 8:30 A. M. The last d&ntal examination for Gltent 3 was dated iged that the clitf rrt*s denttst \ to eatcti up on all of tfie dental W 369 483.4eO(k)(2.) DRUG AOMWISTFtAT ION The system for drug administration rfvust assure that afl drugs, including those that are self-administered, are administered wttteut efror W 352,willing to work with this population, and the Denti- Cal reimbursement it is difficult to get dental work scheduled in a timely manner. The nurses will continue to work closely the dentists to ensure timely dental care. wi th W 369'Staff error. Staff has been counseled/re— trained in medication administratic 7/8/07 FORM CMS-2567(02-89) Previous Versions GbsotehS Event ID G8D5M Facility 10 CA0900QQ745 If continuation sheet Page 6 of 12 DEPARTMENT OF HEALTH AND HIW CERVICES CENTERS FOR MEDICARE & MEDICAIL oERVIGES PRINTED: 06/21/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION ) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 05G080 (X2) MULTIPLE CONSTRUCTION A. BUILDING 6 WING (X3) DATE SURVEY COMPLETED 06/08/2007 NAME OF PROVIDER OR SUPPLIER MONTGOMERY HOUSE STREET ADDRESS, CITY. STATE. ZIP CODE 1658 MONTGOMERY OR VISTA, CA 92083 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) |X5) COMPLETION DATE W 369 Continued From page 6 This STANDARD is not met as evidenced by Bases on observation, interview, and record review the facility failed to ensure that all drugs were administered without error for 1 of 3 sampled clients (2). Findings: Medication storage inspection was completed on 6/07/07 at 12:15 P.M. During inspection of the medications stored in the refrigerator it was noted that the medication pack for Client 2's^ffj^ contained a tablet still in the bubble pack labeled 6/06. The physician's orders for Client 2 were then reviewed The physician had ordered one tab (tablet) at 8:00 P.M. The meclrigdministration record indicated that had been administered on 6/06/07 at owever, the medication for the 8:00 dose for 6/Q6/Q7 wasstijj }n the medication i interviewed at 12'30 acknowledged that the had not beeruldmtrtistered to Client 2 buuHras documented on the medication administration record that the drug had teeiert administrated. W 383 483.4©0(])(E) DRUG STORAGE AND RECORDKEEPING Only authorized persons may have access to the keys to the drug storage area. This STANDARD is not met as evidenced by: Based on observation and interview, the facility failed to ensure that only authorized personnel W369] procedures. R.N. responsible for trailing/ overseeing staffmedicatioi administration. Medication keys are now secured in a locked area inaccessible to clients. ^^^1 responsiblefor ensur security of medications. /8/07 FORM CMS-2567(02-99) Previous Versions Obsolete EvemlD G8D511 Facility ID' CA090000745 If continuation sheet Page 7 of 12 DEPARTMENT OF HEALTH AND HUmAf "ERVICES CENTERS FOR MEDICARE & MEDICAIL PRINTED: 06/21/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (xi) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 05G08D (X2) MULTIPLE CONSTRUCTION A BUILDING B. WING (X3) DATE SURVEY COMPLETED 06/08/2007 NAME OF PROVIDER OR SUPPLIER MONTGOMERY HOUSE STREET ADDRESS. CITY. STATE, ZIP CODE 1658 MONTGOMERY DR VISTA, CA 92083 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ' ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL ' PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION) '• TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE W 383 Continued From page 7 W 383' had access to the drug storage areas. Findings' i An initial tour and general observation of the ; facility was conducted on 6/06/07 at 5:30 A.M. At 6:18 A.M. it was noted that the keys to the medication cabinet were lying onte|0f£jy|oh$ri ' counter. At 6,.;45 A:,M: the^^Smjffff^ to the medication cabinet andmen placed them in , a kitchen drawer and left the kitchen. Client 1 was left alone in the kitchen At 7:00 A.M. Client 1 and Client 4 were observed alone in (he kitchen. Both clients had access to the . j medication keys that were left in the kitchen i drawer. ' j During an intervie^wittitheM|H| on 6/06/07, i j at 8:30 AM, the|HI acknowledged that the \ medication keys weTelenin the kitchen drawer ! and, therefore, accessible to the clienls in the • • house. i W388 483.460(m)( 1)(i) DRUG LABELING W 388 j Labeling for drugs and btoiogicalB must ti& based on currently accepted professional principtes and practices. This STANDARD is not met as evidenced by: Based on observation and interview the facility failed to ensure that the labeling of 1 medication was in accordance with currently accepted professional practices. Findings: A medication storage inspection was Medication labeled. has been proper! R,M. responsible for reviewing medications they are delivered to proper labeling. 78/07 y when ensure FORM CMS-2567(02-99) Previous Version* Obsolete EvemlO Q8D511 Faoflity 10 CA090000745 If continuation sheel Page 8 of 12 DEPARTMENT OF HEALTH AND HL...,ap CERVICES CENTERS FOR MEDICARE & MEDICAIL oERVlCES PRINTED: 08/21/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT Of DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 05G080 (X2) MULTIPLE CONSTRUCTION A. BUILDING B WING (X3) DATE SURVEY COMPLETED 06/08/2007 NAME OF PROVIDER OR SUPPLIER MONTGOMERY HOUSE STREET ADDRESS, CITY. STATE. ZIP CODE 1658 MONTGOMERY OR VISTA, CA 92083 (XI) ID SUMMARY STATEMENT Of DEFICIENCIES ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (Ml COMPLETION DATE W 388 Continued From page 8 on 6/07/07 at 12:30 P.M. A 974 ml. (millilitef) bottle was labeled by the manufacturer ' Solution 10g (grams)/15ml. A was placed on the manufacturer's bottle that read 10§/15m] solution" The Acting ^ckrvowredged that (he medication was improperly labeled during an interview at 12:50 P.M. on 6/07/07 Thef||| removed the medication from the medication storage cabinet. W 390 483.460(m)(2)(i) DRUG LABELING The facility must remove from use outdated drugs. This STANDARD is not met as evidenced by: Based on observation and interview, the facility failed to remove from use 2 medications that were outdated and 2 medication carpules with no known expiration dates Findings' 1. A 30 ml (rnilliliter) bottle of ipecac syrup that was in the fi^^i£krth*^B^^rrtort date of medication was expired, during an interview on 6/7/07 at 110 P M., and placed the ipecac in trie medication discard box. A 4 Ib. (pound) box of magnesium sulfate (epsom salt) located in the medication cabinet had an expiration date of 4/07. medication had expired, during an interview on 6/06/07 at 8 30 A.M., and removed the medication from the house W 388 i i W 390-78/07 K.N. is responsible for reviewing medications and ensuring that outdated medications are removed from use and replaced. FORM CMS-2567(02-99) Previous Verstons Obsolete Event ID G8D511 Facility ID CA09QQOQM5 (f continuation sheet Page 9 o( 12 DEPARTMENT OF HEALTH AND HU,,^' SERVICES CENTERS FOR MEDICARE & MEDICAIL .cRVICES PRINTED: 06/21/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPUER/CUA IDENTIFICATION NUMBER 05G080 (X2) MULTIPLE CONSTRUCTION A BUILDING B WING (X3) DATE SURVEY COMPLETED 06/08/2007 NAME OF PROVIDER OR SUPPLIER MONTGOMERY HOUSE STREET ADDRESS. CITY. STATE, ZIP CODE 1658 MONTGOMERY DR VISTA, CA 92083 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION) , TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION W 390 Continued From page 9 2. There were 8 carpules of spirits of ammonia stored in the first aid kit. Six of the carpules appeared new and had an expiration date of 5/09. Two of the carpules appeared old. There was no expiration date found on these 2 carpules. During an interview with (he Qualifed Mental Retardation Professional ^jjjj^ on 6/07/07 at 1:10 P.M., the: mi acknowledged that there were no expiration dates and placed the 2 Carpules in the ; medication discard box. ' ; W 426 483.470(d)(3) CLIENT BATHROOMS The facility must, in areas of the facility where clients who have not been trained to regulate water temperature are exposed to hot water, ensure that the temperature of the water does not exceed 110 degrees Fahrenheit This STANDARD is not met as evidenced by: Based on observation and interview the facility failed to ensure that the water temperature in the client's bathrooms did not exceed 1 10 degrees Farenheit Findings On 6/07/07 an inspection of the contf ustfd Wtffl measure the water temperature Of the water in the etents bathroom. The temperature of the water in the bathroom off of the bedroom of the 2 male clients measured 116 degrees Farenheit. The mi acknowledged that the water temperature exceeded 110 degrees Farenheit During the physical environment tour the hot W 390 Maintenance constructed a box over the temperatur^ control to ensure that clients did not have access i Maintenance Supervisor I responsible for ensuring j I that clients can not access temperature control on W426! water heater. 78/07 FORM CMS-2567(02-99> Previous Versions Obsolete Even! ID G8Q511 Ftolily ID CA090000N5 If continuation sheet Page 10 of 12 DEPARTMENT OF HEALTH AND HU,.,,V CERVICES CENTERS FOR MEDICARE & MEDICAID PRINTED: 06/21/2007 FORM APPROVED OMB NQ. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPUER/CLIA IDENTIFICATION NUMBER 05G080 (X2) MULTIPLE CONSTRUCTION A BUILDING B WING (X3) DATE SURVEY COMPLETED 06/08/2007 NAME OF PROVIDER OR SUPPLIER MONTGOMERY HOUSE STREET ADDRESS. CITY. STATE. ZIP CODE 1658 MONTGOMERY OR VISTA, GA 92083 (X4)ID SUMMARY STATEMENT OF DEFICIENCIES IO PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION) fAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE W 426 Continued From page 10 water heater was observed to be located in the garage just to the left of the door leading from the house into the garage The temperature control for the hot water heater was located on the front lower psrtioh of the water heater about 2 1/2 feet above the garage fto@T. During an interview with thellH| conducted on 6/07/07 at 2 10 P.M., the jpBpjB. asked if the clients used the garage. meJd replied that the clients help fold wash in the area just next to the hot water heater The JJ^ also stated that the clients in the facility were''"quick and curious." The HJ^| acknowledged that the clients could access the temperature controls on the hot water heater. W 439 483.470(:h>(2) EMERGENCY PLAN AND PROCEDURES The facility must communicate, periodically review, mates the plan available, and provide training to the staff This STANDARD is not met as evidenced by: Based on observation and interview, the facility failed to ensure that all staff were abfe to locate the shut-off valve and be able to shut off the main gas supply to the facility. Findings; On 6/07/07 a physical:etw . consteted with their &nt inspection | was ^Siked'whs^fe fife mate stun-off i gas to the faotfty was located. The id 1 dopt fenpw," Ttlf Acting W4261 W439 ! All facility staff have i been trained on where • to locate main gas shut- 1 off valve. The rusty i valve has been replaced bj • maintenance staff. 78/07 ensui on responsible for staff are trained disaster plan. Maintenance Supervisor responsible for ensuring • shut-off ing FORM CMS-Event ID-G8D511 Facility ID. CA090&Q0745 If eonttnuation sheet Page 11 of 12 California Department of Health Services PRINTED: 05/18/2007 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING B. WINGCA090UU0745 Ub/18/200/ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE, ZIP CODE MONTGOMERY HOUSE 1658 MONTGOMERY DR VISTA, CA 92083 (X4) ID PREFIX TAG BOOO SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Initial Comments The following reflects the findings of the California Department of Health Services during the investigation of one (1) entity reported incident. Entity reported incident: CA001 14303 Representing the Department: Aty Knooren, HFEN. The inspection was limited to the entity reported incident investigated and does not represent the findings of a full inspection of the facility. No deficiencies were issued for entity reported incident CA001 14303 •.. . < ID PREFIX TAG BOOO PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ; '' (X5) COMPLETE DATE LABORATORY DIRECTOR'S OR PROVIDE/SUPPLIER REPRESENTATIVE'S^IGNATUR TITL (X6)DATE STATE FORM BS3511 If continuation sheet 1 of 1 California Department of Health Services FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PRQVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: CA090000745 (X2).MULTIPLE CONSTRUCTION A. BUILDING B. WING._ (X3) DATE SURVEY COMPLETED 04/06/2007 NAME OF PROVIDER OR SUPPLIER MONTGOMERY HOUSE STREET ADDRESS. CITY, STATE, ZIP CODE 1658 MONTGOMERY DR VISTA, CA 92083 (X4)ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X5) COMPLETE DATE BOOO B161 Initial Comments The following reflects the findings of the California Department of Health Services during the investigation of one (1) entity reported incident. Entity reported incident CA00107666 Representing the Department: Aty Knooren, HFEN. The inspection was limited to the entity reported incident investigated and does not represent the findings of a full inspection of the facility. T22 DIV5 CH8.5 ART3-76860(b) Developmental Program Services-Individual S (b) The individual service plan shall be implemented as written. This RULE: is not met as evidenced by: Based on interview and record review the facility failed to implement the individual service plan (ISP)as written for Client A. As a result the direct care staff (DCS) used more restrictive methodology than what was required in the ISP. Findings: According to the client's face sheet, Client A was admitted to the facility onl1/01/89with WfUjflM The individuaTservic^lari (ISP) dated4/14/06 indicated that Client A had a behavior plan in place for tantrum buildup and tantrum behavior. BOOO B161 LABORATORY DIECTORS OfifPROVIDER/SUPPUER REPRESENTATIVE'S SIGNATURE STATE FORM JI36 If continuation sheet 1of7 California Department of Health Services PRINTED: 04/19/2007 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/5UPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETEDA. BUILDING B. WINGCA090000745 " " 04/06/2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MONTGOMERY HOUSE 1658 MONTGOMERY DR - VISTA, CA 92083 (X4) ID PREFIX TAG B161 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From Page 1 The facility's director of adult services (DAS) was interviewed on 3/2/07 at 2:30 P.M. Per the DAS, direct care staff (DCS 1) reported an alleged abuse incident on 2/27/07. The incident occurred between Client A and DCS 2 on 2/20/07 in the evening. According to the director, the investigation was currently in progress with the involved staff. DCS 1 was interviewed on 3/2/07 at 3:00 P.M. According to DCS 1JJB observed DCS 2 agitating Client A JBwas instructed to lay down on the floor, with ^nands toll side. Then DCS 2 sat on Client A with Jpnees between 0 shoulder blades. Per DCS 1 1 was gotten up from the floor by DCS 2 and DCS 3 in the kitchen and taken to the dining room, wherei| was told to lay on the floor again. DCS 1 said •1 could not see what was going on from where BJ was butlj| could hear Client A saying that IJ was sorry, d was then sent to the shower. According to DCS 1 IJ| did not report the incident right away because •• wasn't sure ifit was abuse or not TheuCS 1 stated that ••waited until IJj saw another staff member on2/27/07, who encouraged IJ to report the incident. The DCS 2 was interviewed on 3/2/07 at 3:30 P.M. DCS 2 stated, "Client A started to bitefj hand after being asked to take out the garbage. SautomaticallyplacedBJ hands behind IJ| to p biting and j| was escorted to the dining room. • automatically dropped to the floor, with •J hanostoBJ side and I fell on top oflj I started to get up and l| started to kick, so 1 held Pwith my legs. DCS 3 heldH shoulders so vouldn't bangBJ head. BJwas calm after 5 minutes, J picked upflj shirt thatflj ripped and Sthe connect 4 game, thatlj started to play. was OK after 20 minutes". ID PREFIX TAO B161 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE STATE FORM JI3611 If continuation sheet 2 of 7 California Department of Health Services r l MM I UU. vt/ I 0/i.wt/r FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER MONTGOMERY HOUSE (X4) ID PREFIX TAG B161 B244 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: CA090000745 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 04/06/2007 STREET ADDRESS, CITY, STATE, ZIP CODE 1658 MONTGOMERY DR VISTA, CA 92083 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From Page 2 According to the Adaptive Behavior Support Plan (ABSP) for tantrum-build up dated 3/06, the staff response for the targeted behaviors included counseling, reassurance, keeping the client on task and a PRN {as needed) medication administration. The PRN medication that was ordered by the physician wasHH 5 mg. one tablet every one hour as needed^or agitation not to exceed 4 in 24 hours. The ABSP for tantrums dated 3/06 included the following: the administration of a PRN, having the client lie down until calm, using a firm voice and physical assist as needed, once calm have client complete a 20 minute large motor activity, such as sweeping and to ask 5 questions about ^jj environment. Per the ABSP if the client could complete this without reverting to a tantrum, | could then be reintegrated into the group or activity. If | could not, then^j should continue the large motor activity. flU^Bwasinterv!ewedori4^7at9:OOM/l. TheH^I acknowledged that the client was not offere^aPRN and the ABSP for tantrum build-up and tantrums was not implemented as written by the DCS. T22 DIV5 CH8.5 ART3-76869(c)(2)(F) Developmental Program Services-Behavior Mana (F) A baseline data collection system which addresses the maladaptive behaviors. This RULE: is not met as evidenced by: ID PREFIX TAG B161 B244 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) &W-f MN|te» COW>$^*0- OwxtrT ®{(&b<A\ V&5|U*r<S'tV»tfllT& -W" J ' -W 4 e^et^iViv^^doai\6^«****<*i* . 1 1*"| * iv»^4« **•• (X5)COMPLETE DATE •H* icyl STATE FORM JI3611 K continuation sheet 3 of 7 California Department of Health Services PRINTED: 04/19/2007 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER MONTGOMERY HOUSE - <X4) ID PREFIX TAG B244 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: CA090000745 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 04/06/2007 STREET ADDRESS. CITY, STATE, ZIP CODE 1658 MONTGOMERY DR VISTA, GA 92083 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From Page 3 Based on interview and record review the facility failed to enter a behavior occurrence in the data collection system for Client A. Findings: According to the clients face sheet, Client A was admitted to the facility on 11/01/89 with diagnoses that included I^I^IHH •HHm The individual service plan(ISP) aated4/14/06 indicated that Client A had a behavior plan in place for tantrum buildup and tantrum behavior. DCS 2 was interviewed on 3/2/07 at 3:30 P.M. DCS 2 stated, "Client A started to bite|3• hand after being asked to take out thegarbage. ^ then placed 0 hands behind 0| to stop biting and |H was escorted to the dining roornjl automatically dropped to the floor, with^nands to ^ side and 1 fell on top ofHj ' started to get up and • started to kick, so 1 heldH with my legs. DCS 3 held •shoulders so jf wouldn't bang^ headjB was calm after 5 minutes, | picked upjfsnirt that|| ripped and S' the connect 4 game, that| started to play, was OK after 20 minutes". According to the Adaptive Behavior Support Plan (ABSP) for tantrum-build up dated 3/06, the staff response for the targeted behaviors included counseling, reassurance, keeping the client on task and a PRN (as needed) medication administration. The PRN medication that was ordered by the physician wasHHj 5 rhg. one tablet every one hour as needed, for agitation not to exceed 4 in 24 hours. The ABSP for tantrums dated 3/06 included the following: the administration of a PRN, the client lie down having until calm, using a firm voice ID PREFIX TAG B244 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) i (X5) COMPLETE DATE STATE FORM JI3611 If continuation sheet 4 of 7 California Department of Health Services FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETEDA. BUILDING B. WING CA090000745 04/06/2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MONTGOMERY HOUSE 1 658 MONTGOMERY DR VISTA, CA 92083 <X4) ID PREFIX TAG B244 B617 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From Page 4 and physical assist as needed, once calm have client complete a 20 minute large motor activity, such as sweeping and to ask 5 questions about | environment. Per the ABSP if the client could complete this without reverting to a tantrum, | could then be reintegrated into the group or activity. If | could not, then J| should continue the large motor activity. The data collection sheets for tantrum build-up and for tantrums was reviewed on 4/6/07 at 9:00 A.M. According to the data sheets the behavior that occurred on 2/27/07 for Client A was not found in the clinical record. The director of adult services was interviewed on 4/6/07 at 10:00 A.W. H acknowledged that the narrative entry ted to the behavior was not documented T22 DIV5 CH8.5 ART4-76916(d) Policies and Procedures (d) All policies and procedures required by Section 76916 shall be in writing, made available upon request to clients or their agents, employees and the public, and shall be carried out as written. Policies and procedures shall be reviewed at least annually, and revised as needed. This RULE: is not met as evidenced by: Based on observation, interview and record review the facility's staff failed to report an alleged physical abuse immediately, as directed in the facility's policy and procedure. Findings: According to the client's face sheet, Client A was admitted to the fac lity on 1 1/01/89 with ID PREFIX TAG B244 8617 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) -fkfe, s^# WeM^ W U&&A. GyiM)t>&\€0 \&*AfQi'ftf\ W-fa» We ^o Vfc^v-f "^tf- 0Cv AWt>«. ^fo/#/V"k<V\ #VU* dMMA,\ Update*. D\t^W o £ M^tt s^A^s f&£rtf{\&'\Cnc. ^W QWy\w\t\&i, jfoh -Wo ip i& P«W v c\*A tit^^w-,/" <X5) COMPLETE DATE 1H* STATE FORM JI3611 If continuation sheet 5 of 7 California Department of Health Services PRINTED: 04/19/2007 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER MONTGOMERY HOUSE (X4) ID PREFIX TAG B617 (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: . » „ -A. BUILDING B. WINGCA090000745 STREET ADDRESS, CITY, STATE, ZIP CODE 1658 MONTGOMERY DR VISTA, CA 92083 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From Page 5 diagnoses that included •^•H dIBIIi The individuaRerviceplan (ISP) dated 4/1 4/06 indicated that Client A had a behavior plan in place for tantrum buildup and tantrum behavior. The facility's director of adult services (DAS) was interviewed on 3/2/07 at 2:30 P.M. Per the DAS, direct care staff (DCS 1) reported an alleged abuse incident on 2/27/07, that occurred between Client A and DCS 2 on 2/20/07, in the evening. According to the director, the investigation was currently in progress with the involved staff. DCS 1 was interviewed on 3/2/07 at 3:00 P.M. According to DCS 1, when Client A wouldn't take out the garbage^| observed DCS 2 agitating Client A.DCS2 instructed the client to lay down on the floor, with d hands toH side. Then DCS 2 sat on Client A with fj| knees between • shoulder blades. Per DCS 1 1 was gotten up from the floor by DCS 2 and DCS 3 in the kitchen and taken to the dining room, where Svas told to lay on the floor again. DCS 1 said could not see what was going on from ire |^ was but0| could hear Client A screaming and saying thatj was sorry. |jwas then sent to the shower. The DCS 2 was interviewed on 3/2/07 at 3:30 P.M. DCS 2 stated, "Client A started to bite| hand after being asked to take out the garbage. K automaticallyplacedd hands behind (J to stop biting and || was escorted to the dining room. • automatically dropped to the floor, with d hands to d side and 1 fell on top ofHJ 1 started to get up and| started to kick, sol held Swith my legs. DCS 3 heldH shoulders so vouldn't bangd head. §|was calm after 5 utes, | picked up| shirt that| ripped and ID PREFIX TAG B617 (X3) DATE SURVEY COMPLETED 04/06/2007 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) A^AjArtMc-- (X5) COMPLETE DATE STATE FORM JI3611 If continuation sheet 6 of 7 California Department of Health Services FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION <X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETEDA. BUILDING B. WINGCA090000745 04/06/2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MONTGOMERY HOUSE 1658 MONTGOMERY DR VISTA, CA 92083 (X4JID PREFIX TAG B617 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From Page 6 B' the connect 4 game, thatH started to play, was OK after 20 minutes . Client A was interviewed on 4/6/07 at 8:30 A.M. 0 stated that| liked living at the house and that the people there were nice to0| f| denied that there were any problems. According to DCS 1 ^ did not rePort tne incident right away because!! wasn't sure if it was abuse or not. The DCSistated thatfl waited until m saw another staff member on 2/27/07, who encouraged |J to report the incident. The DCS acknowledged thatlj| had received abuse training when (• was hired however, H| did not follow theracility's policy and procedure for reporting suspected abuse immediately to a supervisor. ID PREFIX TAG B617 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE STATE FORM JI3611 If continuation sheet 7 of 7 DEPARTMENT OF HEALTH AND HUM/ SERVICES CENTERS FOR MEDICARE & MEDICAIPY^/ICES rwiNitu: U5/01«U06 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVlDER/SUPWlER/CUA (X2) MULTIPLE CONSTRUCTION ^* (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED 05G080 B.WING_04/24/2006 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1658 MONTGOMERY ORMONTGOMERY HOUSE ™~" ~"' . ™T,VISTA, CA 92083 (X4)ID PREFIX TAG W156 W183 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 11 Facility incident/accident togs were reviewed on 4/19/06. According to an incident report, dated 12/23/05, Client 1 displayed aggressive behavior, hitting and scratching Client 2 on the face. Documentation on the forms indicated the allegations were investigated, however the abuse allegation was not reported to the appropriate State Agency. According to the facility abuse policy, all allegations of abuse were to be reported to the Department of Health Services within 24 hours. TheincJdent^ccidentlogswererev|ewedwW acTnowTedged the facility failed to implement their policy for reporting all allegations of abuse to the appropriate state agencies. 483.430(c)(2) FACILITY STAFFING There must be responsible direct care staff on duty and awake on a 24-hour basis, when clients are present, to take prompt appropriate action in case of injury, illness, fire or other emergency, in each defined residential living unit housing: (i) Clients for whom a physician has ordered a medical care plan; (ii) Clients who are aggressive, assaultive or . security risks; (ill) More than 16 clients; or (iv) Fewer than 16 clients within a multi-unit building. This STANDARD is not met as evidenced by: Based on observation, interview, and record ID PREFIX TAG W156 W183 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Overnight staff are available to deal with any situation that may occur at night. If we need to supplement this staff and/o have an awake staff due to specific needs, of an individual, we do so. The overnight staff is also expected to sleep in the livingroom, if necessary. m responsible for assuring appropriate staffing to meet the needs of the clients. <XS) COMPLETION DATE 5/24/06 r FORM CMS-2W7(02-OT) Piwtout Vmton* Obtotete Event ID: GAJ511 CA090000745 If continuation sheet Page 12 of 24 DEPARTMENT OF HEALTH ANP 1JUMAN SERVICES CENTERS FOR MEDICARE & to. _.CAJD SERVICES PRINTED: 05/01/2006 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER MONTGOMERY HOUSE (X4)ID PREFIX TAG W183 (X1) PROVIDER/SUPPLIER/CLIA (X2> MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER ^ ^^ 056080 B WING STREET ADDRESS. CITY, STATE, ZIP CODE 1658 MONTGOMERY DR VISTA, CA 92083 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 12 review, the facility failed to provide awake overnight staff, for 3 of 3 sampled clients (1 ,2,3), and, 3 clients added to the sample (4,5,6). Findings: Direct Care Staff (DCS) 1 was interviewed on 4/19/06, at 5:00 P.M. • stated that all of the clients were on behavior programs for behaviors such as aggression, self-injurious behaviors, anxiety, tantrum build up, and tantrums. DCS 3 was interviewed on 4/20/06, at 8:55 A.M. •• stated m lived at the house and was alone wrth the clients from 9:00 P.M. until 6:30 A.M. In addition, • worked at the house from 6:30 A.M. until 9:00 AM. and • worked at the stables from 9:00 A.M. until 2:5o P.M. Staff quarters were located on a level below the main house. ^| stated H| slept on a day bed in the living room of the main house during the night. •I usually toileted Client 1 and Client 2 at 9:00 P.M. and 10:30 P.M. If the client's needed^ they would wake J| up during the night Review of the incident/accident reports for April 2005 through April 2006 revealed that Client 1 was aggressive towards others and sustained multiple falls, which required medical interventions; Client 2 displayed aggressive behaviors towards others; Client 3 displayed aggressive behaviors; Client 5 displayed serf-injurious behaviors and anxiety; and Client 6 displayed aggressive behaviors. Medical records were reviewed on 4/20/06, and revealed that all clients in the facility had behavior programs for maladaptive behaviors. The acting Qualified Mental Retardation ID PREFIX TAG W183 (X3) DATE SURVEY COMPLETED 04/24/2006 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE FORM CMS-2Sfl7(02-99) Pwvtous Version* Obiotete Event IO: GAJ511 Faculty »: CA00000074S If continuation sheet Page 13 of 24 apartment of Health and Human Service' Jenters for Medicare & Medicaid Service Form Approved OMB NO. 0938-0390 Post-Certification Revisit Report Public reporting for this collection of information is estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing the burden, to CMS, Office of Financial Management, P.O. Box 26684, Baltimore, MD 21207; and to the Office of Management and Budget, Paperwork Reduction Project (0938-0390), Washington, D.C. 20503. (Y1) Provider/ Supplier /CLIA/ Identification Number 05G142 (Y2) Multiple Construction A. Building B. Wing Name of Facility VISTA HOUSE (Y3) Date of Revisit 12/9/2008 Street Address, City, State, Zip Code 1768 MONTE MAR ROAD VISTA, CA 92084 This report is completed by a qualified State surveyor for the Medicare, Medicaid and/or Clinical Laboratory Improvement Amendments program, to show those deficiencies previously reported on the CMS-2567, Statement of Deficiencies and Plan of Correction that have been corrected and the date such corrective action was accomplished. Each deficiency should be fully identified using either the regulation or LSC provision number and the identification prefix code previously shown on the CMS-2567 (prefix codes shown to the left of each requirement on the survey report form). (Y4) item (Y5) Date (Y4) Item (Y5) Date (Y4) item (Y5L Date ID Prefix W0120 Correction Completed 12/09/2008 Reg.# 483.4io(d)(3) LSC ID Prefix W0326 Correction Completed 12/09/2008 Reg. # 483.460(a)(3)(iii) LSC ID Prefix W0426 Correction Completed 12/09/2008 Reg. # 483.470(d)(3) LSC ID Prefix Correction Completed Reg.# LSC ID Prefix Correction Completed Reg.# LSC Reviewed By State Agency Reviewed By CMSRO Review&d By Reviewed By Followup to Survey Completed on: 11/20/2008 ID Prefix Reg.# LSC ID Prefix Reg. # LSC ID Prefix Reg.# LSC ID Prefix Reg.# LSC ID Prefix Reg. # LSC Correction Completed W012S 12/09/2008 483.420(a)(3) Correction Completed W0352 12/09/2008 483.460(f)(2) Correction Completed W0440 12/09/2008 483.470(0(1) Correction Completed Correction Completed ~Dater Date: ID Prefix W0215 Correction Completed 12/09/2008 Reg. # 483.440(c)(3)(iv) LSC ID Prefix W0390 Correction Completed 12/09/2008 Reg. # 483.460(m)(2)(i) LSC ID Prefix W0443 Correction Completed 12/09/2008 Reg. # 483.470(i)(1)(ii) LSC ID Prefix Correction Completed Reg.# LSC ID Prefix Correction Completed Reg.# LSC Signature of Surveyor: ~K3^J2—\jSignature of Surveyor: Check for any Uncorrected Deficiencies. Was a Summary of Uncorrected Deficiencies (CMS-2567) Sent to the Facility? Date: '^42^08 Date: YES NO Form CMS - 2567B (9-92)Page 1 of 1 Event ID: RBMS12 DEPARTMENT OF HEALTH AND HUIV CERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 11/25/2008 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 05G142 (X2) MULTIPLE CONSTRUCTION A. BUILDING B WING (X3) DATE SURVEY COMPLETED 11/20/2008 NAME OF PROVIDER OR SUPPLIER VISTA HOUSE STREET ADDRESS, CITY, STATE, ZIP CODE 1768 MONTE MAR ROAD VISTA, CA 92084 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES | ID (EACH DEFICIENCY MUST BE PRECEDED BY FULL I PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) j TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE WOOD | INITIAL COMMENTS i I The following represents the findings of the ! California Department of Public Health during a ! FUNDAMENTAL survey visit. I i Representing the Department: i Christine Reed HFEN WOOD W120 i The facility census was 6 clients. The sample size was 3 clients, 483.410(d)(3) SERVICES PROVIDED WITH OUTSIDE SOURCES the facility must assure that outside services irneet the needs of each client. This STANDARD is not met as evidenced by: Based on observation and interview, the facility failed to ensure that 2 of 3 sampled clients (1, 3) had a change of clothes at day program in the event that their clothes became soiled. Findings: 1. Client 1 was admitted to the facility on 11/15/88 with diagnoses that included i •, / \ " nd V ocording to the Client Identification and tmergency Information Sheet. Client 1 was observed at day program on 11/18/08 at 11:00 A.M. An interview was conducted with Client 1's day program instructor on 11/18/08 at 11:05 A.M. Client 1's day program instructor was asked if Client 1 had a change of clothes in case ^fclothes became soiled. The day program instructor stated that about a week ago Client 1 had an episode or urinary W120 The facility shall assure that outside services meet the needs of each client. Thel ss bought communication books and have trained both the home and day program staff of their use, The { shall ensure communication between the home and day program by utili7inn i-he communication log. The', 'ill monitor by routine communication with the house manager and day program instructor to ensure that this regulation continues to be met. 11/21/08 E /KJ [p n \\ 7 Tr(G Is II w IE DEC 00 -9 2m LICENSING AND CERTIFICATION SAN DIEGO DISTRICT OFFICE SOUTH Any deficiency statement ending with an asterisk (*) denotes a deficiency which the instlretion may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RBMS11 Facility ID: CA090000220 If continuation sheet Page 1 of 13 DEPARTMENT OF HEALTH AND HUlv. CERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 11/25/2008 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPUER/CLIA IDENTIFICATION NUMBER: 05G142 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 11/20/2008 NAME OF PROVIDER OR SUPPLIER VISTA HOUSE STREET ADDRESS, CITY, STATE, ZIP CODE 1768 MONTE MAR ROAD VISTA, CA 92084 (X4)ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE W 120 ; Continued From page 1 I incontinence (inability to control urine) and soiled lothes. The day program assisted Client 1 to \ change into the clothes thatf" group home had | supplied. Since that time, thv. .dcility had not | replaced Client 1's change of clothes. The day program instructor stated that Client 1 had episodes of urinary incontinence about once a month. An interview was conducted with thev nouse Manager (HM) on 11/iy/UB at /:4b A.M. Neither the^ 'nor the HM were aware that Client 1 had an episode of urinary incontinence at day program. Therefore, they were not aware that Client 1 had no change of clothes at day program. 2. Client 3 was admittpH 11/1 8/02 with < _ the facility on fcincludedl according to the Client Identification and Emergency Information Sheet. Client 3 was observed at day program on 11/18/08 at 10:35 A.M. An interview was conducted with Client 3's day program instructor on 11/18/08 at 10:45 A.M. The day program instructor stated that Client 3 had an episode of urinary incontinence (inability to control urine) about a week ago. The day program staff used the change of clothes in Client 3's backpack to replace soiled clothing. The day program instructor stated thatl was not sure if another change of clothes had been placed in Client 3's backpack. At 11:00 A.M. on 11/18/08, Client 3's backpack was checked to see if their was a change of clothes. There was' no change of W120 FORM CMS-2567(02-99) Previous Versions Obsolete EventlD:RBMS11 Facility ID: CA090000220 If continuation sheet Page 2 of 13 DEPARTMENT OF HEALTH AND HUI\ )ERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 11/25/2008 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 05G142 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 11/20/2008 NAME OF PROVIDER OR SUPPLIER VISTA HOUSE STREET ADDRESS, CITY, STATE, ZIP CODE 1768 MONTE MAR ROAD VISTA, CA 92084 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES | ID (EACH DEFICIENCY MUST BE PRECEDED BY FULL ! PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE W 120 Continued From page 2 | clothes present in Client 3's backpack. An interview was conducted with the van driver on 11/18/08 at 11:10 A.M. The van driver was aware that Client 3 had an episode of urinary incontinence. Jid that informed the House Manager (hivl) The about the incident. W 125 An interview was conducted with the HM nn 11/19/08 at 7:45 A.M. The HM said that(_ was not aware that Client 3 had an episode of urinary incontinence at day program. Nor was w/are that Client 3 had used his change of domes after that incident and currently did not have a change of clothes in his backpack. The HM further stated that he is aware that Client 3 has episodes of urinary incontinence approximately once a month. 483.420(a)(3) PROTECTION OF CLIENTS RIGHTS The facility must ensure the rights of all clients. Therefore, the facility must allow and encourage individual clients to exercise their rights as clients j of the facility, and as citizens of the United States, j including the right to file complaints, and the right | to due process. j This STANDARD is not met as evidenced by: Based on interview and record review the facility failed to ensure that current consents were obtained for 1 of 3 sampled clients (3) medical, dental, and surgical treatment, disposition of clothing, visitation, use of a house alarm, locking up of cleaning supplies, and use of the house pool. Findings: W120I W 125! The facility shall ensuje the rights of all clients. The , tailed an additional set of consents to client 3's conservator on 11/19/2008. This regulation will continue to be met by the utilizing random quality assurance audits of the client record conducted by the and the Director of Residential Services. 11/19/08 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RBMS11 Facility ID: CA0900Q0220 If continuation sheet Page 3 of 13 DEPARTMENT OF HEALTH AND HUIV CERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 11/25/2008 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) M AND PLAN OF CORRECTION IDENTIFICATION NUMBER:A. BUI 05G142 BVm NAME OF PROVIDER OR SUPPLIER VISTA HOUSE (X4) ID PREFIX TAG W 125 SUMMARY STATEMENT OF DEFICIENCIES ID (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREF REGULATORY OR LSC IDENTIFYING INFORMATION) TAG Continued From page 3 W ' Client 3 was admitted to the facility on 11/18/02 with diagnoses that included '.--^ according to the Client Identification and Emergency Information Sheet. A review of Client 3's clinical record was conducted on 1 1/20/08 at 1 1:00 A.M. Located in Client 3's clinical record were six consents. The consent for medical, dental, and surgical treatment were signed by Client 3's conservator :ather, and dated 1 1/12/02. The consent clearly stated that "The authorization shall remain in effect for five years..." An interview wqj- ---'ducted with the • • n W215 11/20/08 at 10:30 A.M. The QMKJV' j acknowledged that Client 3's consent for medical, dental, and surgical treatment was not current. The other five consents located in Client 3's clinical record were for disposition of clothing, visitation, use of a house alarm, locking up of cleaning supplies, and use of the house pool. These five consents were all signed by Client 3. There was no date present on any of the consents. /A " 'itepjew was conducted with the* von i i/<iu/u»at 10:30 A.M. acknowledged that the five consents were not valid because they were not signed by Client 3's conservator, father. ULTIPLE CONSTRUCTION LDING G STREET ADDRESS, CITY, STATE, ZIP CODE 1768 MONTE MAR ROAD VISTA, CA 92084 (X3) DATE SURVEY COMPLETED 11/20/2008 PROVIDER'S PLAN OF CORRECTION X (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 25 I 483.440(c)(3)(iv) INDIVIDUAL PROGRAM PLAN W 215 The comprehensive functional assessment must identify the client's needs for services without : regard to the actual availability of the services The facility shall ensure the comprehensive functional assessment identifies the client's needs for services (X5) COMPLETION DATE 12/1/08 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RBMS11 Facility ID: CA090000220 If continuation sheet Page 4 of 13 DEPARTMENT OF HEALTH AND HUIV CERVICES CENTERS FOR MEDICARE & MEDICAIL SERVICES PRINTED: 11/25/2008 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 05G142 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 11/20/2008 NAME OF PROVIDER OR SUPPLIER VISTA HOUSE STREET ADDRESS, CITY, STATE, ZIP CODE 1768 MONTE MAR ROAD VISTA, CA 92084 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG * REGULATORY OR LSC IDENTIFYING INFORMATION) ID PROVIDER'S PLAN OF CORRECTION PREFIX ' (EACH CORRECTIVE ACTION SHOULD BE TAG I CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE W 215 | Continued From page 4 needed. This STANDARD is not met as evidenced by: Based on observation, interview, and record review the facility failed to ensure that 3 of 3 sampled clients (1, 2, 3) had a recreational therapy assessment prior to their annual interdisciplinary (IDT) meeting to develop their individual service plan (ISP). In addition, the facility failed to ensure that 1 of 3 sampled clients (3) with congenital contractures of the lower extremities had a physical therapy assessment. Findings: la. Client 1 was admitted to the facility on 11/15/88 With Hiannncoc that irvMnHnv| _ and* flisorcler according to the Client Identification and Emergency Information Sheet. A review of Client Ts clinical record was conducted on 11/20/08 at 9:40 A.M. The last annual IDT meeting to develop Client 1's ISP was held on 12/20/07. Several multidisciplinary i assessments had been performed prior to the i annual IDT meeting. However, Client 1 did not have a recreational therapy assessment until 12/28/07 which was eight days after the IDT meeting. W215 An interview was mnrinrted with the* >n 11 /20/08 at 10:40 A.M. Ttv acknowledged that the recreational therapy assessment should have been done prior to the IDT meeting to adequately develop an ISP for Client 1. without regard to the actual availability of the services needed. The will ensure that the recreation assessments are completed and received before the IDT meetings in order to adequately develop an ISP for each client. The Director of Residential Services has counseled the Recreation Therapist on ensuring that he is completing assessments the month prior to the ISP. A physical therapy referral has been obtained for client 2 from the primary care physician and a physical therapy assessment will be scheduled by the •The Director of Residential Services anc ~ vill monitor the assessment completion and delivery through random quality assurance audits. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RBMS11 Facility ID: CA090000220 If continuation sheet Page 5 of 13 DEPARTMENT OF HEALTH AND HUIW >ERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 11/25/2008 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 05G142 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 11/20/2008 NAME OF PROVIDER OR SUPPLIER VISTA HOUSE STREET ADDRESS. CITY, STATE, ZIP CODE 1768 MONTE MAR ROAD VISTA, CA 92084 (X4)ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES -%,^| (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE W215 Continued From page 5 1 b. Client 2 was admitted to the facility on 5/7/85 with diaannspc H-i and i W215 according to the Client Identification and Emergency Information Sheet. A review of Client 2's clinical record was conducted on 11/20/08 at 8:15 A.M. The last annual IDT meeting to develop Client 2's ISP was held on 8/21/08. Several multidisciplinary assessments had been performed prior to the annual IDT meeting. However, Client 2 did not have a recreational therapy assessment until 9/12/08 which was three weeks after the IDT meeting. I An with thfi« 11/20/08 at 10:40 A.M. The* acknowledged that the recreational therapy assessment should have been done prior to the IDT meeting to adequately develop an ISP for Client 2. 1c. Client 3 was admitted to the facility_on 11/18/02 with diaanoses that included4~ according to the Cliem identification ana Emergency Information Sheet. A review of Client 3's clinical record was conducted on 11/20/08 at 11:00 A.M. The last annual IDT meeting to develop Client 3's ISP was held on 11/13/08. Several multidisciplinary assessments had been performed prior to the annual IDT meeting. However, Client 3 did not have a recreational therapy assessment until FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RBMS11 Facility ID: CA090000220 If continuation sheet Page 6 of 13 DEPARTMENT OF HEALTH AND HUto 'SERVICES CENTERS FOR MEDICARE & MEDICAll/SERVICES PRINTED: 11/25/2008 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 05G142 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 11/20/2008 NAME OF PROVIDER OR SUPPLIER VISTA HOUSE STREET ADDRESS, CITY, STATE, ZIP CODE 1768 MONTE MAR ROAD VISTA, CA 92084 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES j ID PREFIX I (EACH DEFICIENCY MUST BE PRECEDED BY FULL ! PREFIX TAG I REGULATORY OR LSC IDENTIFYING INFORMATION) j TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5)COMPLETION DATE W215 Continued From page 6 11/18/08 which was five days after the IDT meeting. W-215 An interwi<a»«' ..." • i..~*~r4 >«/j{|-| i on 11/20/08 at 10:40 A.M. The - __ acknowledged that the recreational therapy ; assessment should have been done prior to the j IDT meeting to adequately develop an ISP for j Client 3. ! 2. Client 3 was admitted to the facility on 11/18/02 with diagnoses that included inrl according lOTTO Ultiiu identification and Emergency Information Sheet. Client 3 was observed in the facility on 11/18/08 at 7:20 A.M. Client 3 was helping the direct care staff set up the breakfast bar. Client 3 was observed to ambulate with difficulty because of contractures of the lower extremities. A review of Client 3's clinical record was conducted on 1 1/20/08 at 1 1 :00 A.M. It was documented in the clinical record that Client 3 had congenital contractures of the lower extremities. A physician's order to "Exercise - Stretch both knees 8 A.M. & 4 P.M." was present and dated 8/18/97. However, there was no assessment by a physical therapist present in the clinical record. An i \«;rth tho __ 11/20/08 at 10:50 A.M. The. _ _ stated that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RBMS11 Facility ID: CA090000220 If continuation sheet Page 7 of 13 DEPARTMENT OF HEALTH AND HUM, CERVICES CENTERS FOR MEDICARE & MEDICAID CERVICES PRINTED: 11/25/2008 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 05G142 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 11/20/2008 NAME OF PROVIDER OR SUPPLIER VISTA HOUSE STREET ADDRESS, CITY, STATE, ZIP CODE 1768 MONTE MAR ROAD VISTA, CA 92084 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES i ID (EACH DEFICIENCY MUST BE PRECEDED BY FULL | PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) TAG PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETION CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) W215 W326 W352 Continued From page 7 Client 3 had not had a physical th^^py assessment in the two years that! J had been employed. 483.460(a)(3)(iii) PHYSICIAN SERVICES The facility must provide or obtain annual physical examinations of each client that at a minimum includes special studies when needed. This STANDARD is not met as evidenced by: Based on interview and record review, the facility failed to ensure that 1 of 3 sampled clients (2) had an annual EKG (electrocardiogram) as ordered by her physician. Findings: i i Client 2 was admitted to the facility on 5/7/85 with that inr»hiHc ^according to the Clinic Identification and Emergency Information Sheet. A review of Client 2's clinical record was conducted on 11/20/08 at 8:15 A.M. There was a physician order present and dated 8/17/97 on the clinical record that read "EKG Check Annually." The most recent EKG documented in the clinical record was dated 2006. An interview was conducted with the Registered Nurse (RN) on 11/20/08 at 2:45 P.M. The RN acknowledged that annual electrocardiograms for Client 2 were not being done as ordered by the physician. 483.460(f)(2) COMPREHENSIVE DENTAL DIAGNOSTIC SERVICE W215 W326 W352 The facility shall provide annual physical exams for all clients to include special studies. The] has scheduled Client 2 for an EKG on 12/9/08. The r ~~and Nurse Consultant will ensure that special services are performed as the physician has ordered. The" ind Director of Residential Services shall perform random quality assurance audits to ensure that this regulation continues to be met. 12/9/08 The facility shall ensure comprehensive 11/20/08 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RBMS11 Facility ID: CA090000220 If continuation sheet Page 8 of 13 DEPARTMENT OF HEALTH AND HUIV, SERVICES CENTERS FOR MEDICARE & MEDICAID CERVICES STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X AND PLAN OF CORRECTION IDENTIFICATION NUMBER:A. 05G142 B NAME OF PROVIDER OR SUPPLIER VISTA HOUSE (X4) ID PREFIX TAG W352 SUMMARY STATEMENT OF DEFICIENCIES PRINTED: 11/25/2008 i FORM APPROVED OMB NO. 0938-0391 2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETEDBUILDING WING " " 11/20/2008 STREET ADDRESS, CITY, STATE, ZIP CODE 1768 MONTE MAR ROAD VISTA, CA 92084 ID PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) ! Continued From page 8 W 352 Dental diagnostic services are Comprehensive dental diagnostic services j include periodic examination and diagnosis performed at least annually. i! This STANDARD is not met as evidenced by: Based on interview and record review, the facility ; failed to ensure that 1 of 3 sampled clients (2) had an annual dental examination. Findings: Client 2 was admitted to the facility on 5/7/85 with \ diagnoses that included ~ and' "iccording to the Client Identification and Emergency Information Sheet. A review of Client 2's clinical record was conducted on 11/20/08 at 8:15 A.M. According to documentation in the clinical record, Client 3's last dental examination was performed on 3/8/07. | There was no documentation in the clinical record that Client 3 had a dental examination since that time. Therefore, Client 3 had not had a dental examination for 20 months. W390 An interview was conducted with the Registered Nurse (RN) on 1 1/20/08 at 2:45 P.M. The RN acknowledged that Client 2 had not had dental examinations on an annual basis. performed at least annually. Due to the dentist cancelling all of the clients that needed to be seen client 2 did not have an annual dental appointment. The RN has made an appointmpnt for client 2's dental exam. The _ snd Nurse Consultant shall ensure that the RN schedules and annual dental exams are completed. A tracing system will be utilized to ensure that the RN is always a^are of the last appointment. | The and Director of Residential Services snail perform random quality assurance audits to ensure that this regulation continues to be met. j * 483.460(m)(2)(i) DRUG LABELING W 390 The facility must remove from use outdated drugs. This STANDARD is not met as evidenced by: Based on observation and interview, the facility i The facility shall remove all outdated \ 11/19/08 i drugs. The ~" -emoved all expired medications i ram the facility. The RN, } i FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RBMS11 Facility ID: CA090000220 If continuation sheet Page 9 of 13 DEPARTMENT QF HEALTH AND HUM, CERVICES CENTERS FOR MEDICARE & MEDICAlbCERVICES PRINTED: 11/25/2008 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 05G142 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 11/20/2008 NAME OF PROVIDER OR SUPPLIER VISTA HOUSE STREET ADDRESS, CITY, STATE, ZIP CODE 1768 MONTE MAR ROAD VISTA, CA 92084 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)I ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE W 390 Continued From page 9 failed to ensure that medications that had expired were removed from use. Findings: An inspection of the medication storage area was conducted on 11/19/08 at 9:30 A.M. The following expired medications were found in the facility's first aid kit: 28 iodine prep pads - Expiration date 4/08 2 Iodine prep pads - Expiration date 7/04 2 four ounce bottles of saline eye wash - Expiration date 6/07 1 one ounce bottle of sterile isotonic eye wash - Expiration date 2/03 1 one ounce bottle of sterile isotonic eye wash - Expiration date 7/04 An interview was r.nnriucted with the on W426 11/19/08 at 10:00 A.T/I. the* acknowledged that those 34 medications were expired and should have been removed from the facility. 483.470(d)(3) CLIENT BATHROOMS The facility must, in areas of the facility where clients who have not been trained to regulate i water temperature are exposed to hot water, I ensure that the temperature of the water does not ! exceed 110 degrees Fahrenheit. This STANDARD is not met as evidenced by: ! Based on observation and interview, the facility I failed to ensure that the temperature of the hot water in the client's bathrooms did not exceed 110 degrees Farenheit. W390 W426 Pharmacy and hall perform random facility audits to ensure that all outdated medications are removed from the facility. The facility shall ensure the regulation of the water temperature so that clients are not exposed to water over 110 degrees farenheit. The turned down the hot water neater and retested the hot water with a temp of 107 degrees. The _ 'ill ensure that the house manager monitor the 11/19/08 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RBMS11 Facility ID: CA090000220 If continuation sheet Page 10 of 13 DEPARTMENT OF HEALTH AND HUlv, ^SERVICES CENTERS FOR MEDICARE & MEDICAlu SERVICES PRINTED: 11/25/2008 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 05G142 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 11/20/2008 NAME OF PROVIDER OR SUPPLIER VISTA HOUSE STREET ADDRESS, CITY, STATE, ZIP CODE 1768 MONTE MAR ROAD VISTA, CA 92084 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES ID (EACH DEFICIENCY MUST BE PRECEDED BY FULL , PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) i TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE W 426 | Continued From page 10 i W 426 | | Findings: \ Observation and inspection of the general environment was conduced nn 11/19/08 at 8:00 A.M. At 8-an A M. *h^' -' . , j was asked to check the temperature of the Rot water in a client bathroom. Using a thermometer that read tfimnprotures Up to 120 degrees Farenheit, the :lled a glass with water from the bathroom shower and inserted the thermometer. The I temperature of the shower water was 120 | degrees Farenheit. It could not be determined if the temperature of the water was actually greater than 120 degrees Farenheit. | on 11/19/08 at 8:45 A.M., an interview was ! conducted with the t ^ The ! acknowledged that tne temperature of the shower j water in the client's bathroom exceeded 110 j degrees Farenheit. The further stated that! the 2 clients that use that bathroom are both i | capable of turning on the shower water. W 440 I 483.470(i)(1) EVACUATION DRILLS , W 440 I ! I | ! The facility must hold evacuation drills at least i | quarterly for each shift of personnel. i This STANDARD is not met as evidenced by: Based on interview and record review, the facility failed to ensure that fire drills were held for each shift of personnel each quarter. Findings: A review of the fire and evacuation drills was conducted on 11/19/08 at 1:15 P.M. In January hot water temperature weekly through random facility audits. The facility shall hold evacuation drills monthly on each shift. The ~ ~ shall ensure that monthly drills or;. completed on each shift. The and Assurance supervisor wm monitor nre drills through random audits. 11/19/08 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:RBMS11 Facility ID: CA090000220 If continuation sheet Page 11 of 13 DEPARTMENT OF HEALTH AND HUN ^SERVICES CENTERS FOR MEDICARE & MEDICAlu SERVICES PRINTED: 11/25/2008 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 05G142 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 11/20/2008 NAME OF PROVIDER OR SUPPLIER VISTA HOUSE STREET ADDRESS, CITY, STATE, ZIP CODE 1768 MONTE MAR ROAD VISTA, CA 92084 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES I ID (EACH DEFICIENCY MUST BE PRECEDED BY FULL ! PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) I TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE W 440 Continued From page 11 of 2008, a fire and evacuation drill was conducted on the day shift and the evening shift. In February of 2008, a fire and evacuation drill was conducted on the evening shift. In March of 2008, a fire and evacuation drill was conducted on the evening shift. There was no documentation present that any fire and evacuation drill was conducted on the night shift for the first quarter of 2008. | An interview was conducted with the*__ * ! on j 11/20/08 at 1:10 P.M. The' ; ^CKnuwledged I that a fire and evacuation drill nad not been I conducted at the facility on the night shift during | the first quarter of 2008. W 443 j 483.470(i)(1 )(ii) EVACUATION DRILLS | The facility must hold evacuation drills to ensure | that all personnel on all shifts are familiar with the use of the facility's fire protection features. This STANDARD is not met as evidenced by: Based on observation, interview, and record review the facility failed to ensure that all staff members were knowledgeable of the location of the main gas shut off valve. Findings: Observation and inspection of the general environment was conducted on 11/19/08 at 8:00 A.M. Direct Care Staff (DCS) 2 was asked where the main gas shut off valve for the facility was located. DCS 2 referred to the facility's Fire and Disaster Manual to check the location of the main | gas shut off valve. According to the Fire and I Disaster Manual, the main gas shut off valve was W440 W443 The facility shall hold evacuation drills and ensure that all personnel are familiar with the use of facility fire protection features. Th' '22 changed the working of tne location of the gas shut off in the disaster plan manual. The ' ..so trained all staff on the location of the main gas shut off valve. The QMRP will ensure all staff understand the location and are shown the location during their initial training at the facility and are randomly tested to ensure memory retention. 11/19/08 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RBMS11 Facility ID: CA090000220 If continuation sheet Page 12 of 13 DEPARTMENT OF HEALTH AND HUIV -SERVICES CENTERS FOR MEDICARE & MEDICAli/SERVICES PRINTED: 11/25/2008 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROV1DER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 05G142 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 11/20/2008 NAME OF PROVIDER OR SUPPLIER VISTA HOUSE STREET ADDRESS. CITY, STATE, ZIP CODE 1768 MONTE MAR ROAD VISTA, CA 92084 (X4)ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID I PROVIDER'S PLAN OF CORRECTION PREFIX | (EACH CORRECTIVE ACTION SHOULD BE TAG ! CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE W 443 j Continued From page 12 I located on the "west side of the house, left of | garage behind bushes." Using this description, DCS 2 tried to locate the main gas shut off valve. However, at 8:15 A.M., DCS 2 acknowledged that she was unable to locate the main gas shut off valve. Ai8:20A.M. the *— '. . '-^as asked to locate the main gas shut off valve. Using the same directions from the Fire and Disaster Manual, the • _ J was also unable to locate the main gas shut off valve. An interview was conducted with the ^" » ^n 11/19/08 at 8:25 A.M. The ' "' cknowledged that the directions to locate the main gas shut off valve in the Fire and Diaster Manual were not accurate. The*~7 "further acknowledged that the main gas shut off valve was actually located approximately 50 feet from the garage at the end of the driveway. W443 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RBMS11 Facility ID: CA090000220 If continuation sheet Page 13 of 13 DEPARTMENT OF HEALTH AND HUM, "pRVICES CENTERS FOR MEDICARE & MEDICAID ocRVICES PRINTED: 01/03/2008 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER VISTA HOUSE (X4) ID PREFIX TAG WOOD W359 (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER:A. BUILDING 05G142 BWING STREET ADDRESS.CITY (X3) DATE SURVEY COMPLETED 12/21 /2007 STATE, ZIP CODE 1768 MONTE MAR ROAD VISTA, CA 92084 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) INITIAL COMMENTS The following reflects the findings of the California Department of Public Health during a FUNDAMENTAL survey. Representing the California Department of Public Health: Leslie Roe, HFEN. Then census of the facility during the survey was 6 clients. The sample size was 3 clients. 483.460(h)(2) DOCUMENTATION OF DENTAL SERVICES If the facility does not maintain an in-home dental service, the facility must obtain a dental summary of the results of dental visits. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the facility did not maintain a dental summary of the result of an annual dental visit in the clinical record of 1 of 3 sampled clients (Client 1) which resulted in a failure to know when the appointment was or what occurred at the appointment. Findings : Client 1 was admitted to the facility with diagnoses that included . ~__ per _ lient information sheet. On 12/20/07 at 8:45 A.M. a review of the clinical record of Client 1 was conducted. A note by the registered nurse (RN 1), in the interdisciplinary notes indicated that Client 1 had been scheduled for dental appointments on 2/6/07 and 3/8/07. No summary of any dental appointments in 2007 was present in the clinical record. ID PREFIX TAG WOOD W359 /tff PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) RtOb ACcw/fc oW-tci low <v>Co\l(t *>eM\ fa fij S/ r\6>\ wJ U *c $* \#$ vS U^ 3UX E (G E B W E ff JAN 1 4 2008 L> LICENSING AND CERriFICATION NOIEGODISIRICI OFFICE SOUTH \Utfc o^ *&~ V>i\i-Hj ~\o I III Ad06M,Wtffl"t"(XH V?\\$ (X^^- "it) - dt5tvrie>T cWft' ^ of ^W > r^ttfvv^ibW •>^o^kW (X5) COMPLETION DATE \ //*!/** » LABORATORY PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE'(X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may bfe/excused from correcting providing it is determined th'at other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing Tfomes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7X8211 Facility ID: CA090000220 If continuation sheet Page 1 of 7 DEPARTMENT OF HEALTH AND HUM. <=RVICES CENTERS FOR MEDICARE & MEDICAID odRVICES PRINTED: 01/03/2008 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER VISTA HOUSE (X4) ID PREFIX TAG W359 W368 (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: A. BUILDING 05G142 BWING STREET ADDRESS, CITY, STATE, ZIP CODE 1768 MONTE MAR ROAD VISTA, CA 92084 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 On 12/20/07 at 5:55 P.M. a Joint interview with the ana review of Client i s cimicai ns^uiu was conducted. The *""" "~ stated that she knew Client 1 had been to a dental appointment in 2007, but she was not sure when. She stated that she would have to check elsewhere to determine when Client 1 went to the dentist in 2007. On 12/20/07 at 6:10 P.M. a joint interview with RN 1 , and review of Client 1's clinical record was conducted. RN 1 stated that Client 1's annual dental appointment had "probably" occurred on 3/8/07 based on her note in the interdisciplinary notes in the clinical record. RN 1 stated that she knew that Client 1 had been to the dentist before •-~- called the dentist on 9/20/07 regarding Client 1's broken tooth, because the dentist's recommendations were based on the annual appointment. When asked where the dental summary of that appointment was located in the clinical record, she stated that a Promise Hospital laboratory request form, dated 5/10/07, was the record of Client Ts dental appointment. RN 1 stated that usually there was a written record of appointments, but there appeared to be none in the record of Client 1. On 12/20/07 at 6:35 P.M. during an interview with the ' ohe acknowledged that there was no record in Client 1's clinical record maintained at the house that summarized Client 1's dental appointment in 2007. 483.460(k)(1) DRUG ADMINISTRATION The system for drug administration must assure that all drugs are administered in compliance with ID PREFIXTAG W359 W368 (X3) DATE SURVEY COMPLETED 12/21/2007 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE il*il*r FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7X8211 Facility ID: CA090000220 If continuation sheet Page 2 of 7 DEPARTMENT OF HEALTH AND HUM CENTERS FOR MEDICARE & MEDICAID otfRVICES ^RVICES PRINTED: 01/03/2008 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER VISTA HOUSE (X4) ID PREFIX TAG W368 (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: A. BUILDING 05G142 B'WING STREET ADDRESS, CITY, STATE, ZIP CODE 1768 MONTE MAR ROAD VISTA, CA 92084 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 the physician's orders. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the facility did not assure that all drugs were administered n accordance with the physician's orders when, 1) an antacid and a laxative that were supposed to be chewed were swallowed by 1 of 3 sampled clients (Client 1) and/ 2) one dental medication was not properly administered to 1 of 3 sampled clients (Client 3) for the prescribed amount of time. Findings: 1 . Client 1 was admitted to the facijjtyj/vith ID PREFIX TAG W368 diaanoses that included . _ per *~ client identification sheet. On 12/17/07 at 8:39 P.M. Client 1 was called to the kitchen to receive ^»<->. 00 P.M. medications. The house manager prepared 10 types of medications that Client 1 was going to receive by dispensing the medications into a small medicine cup. The house manager then told Client 1 to swallow the medications with a drink of water. At 8:48 P.M. Client 1 swallowed^^medications from the cup with the exception of one tha* dropped, which was replaced by the house manager and was swallowed several minutes later. At no time was Client 1 observed to chew any of ^•niedications. On 12/20/07 at 10:15 A.M. the clinical record of Client 1 was reviewed. The physician's orders for indicated that Client 1's 8:00 P.M—medications included, "Genasyme 80 mg (milligrams) tablet CHEW GX #62 at 8 P.M. for gas relief," and "Phillips MOM (milk of magnesia) tab CHEW #62 (X3) DATE SURVEY COMPLETED 12/21/2007 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) , £f 1 . L^ , lr v" A r Ctec-JrfAWe M CO \0 //I/AM l^\l£7r£l ^&>(/u/v -V\A /i V f\ C& ~\D \>£- CnTnA/ (A IhA 4wA -msu M t ^-jrz. ( ) \J>-*J\*/ *\^s *^ \<n wAzf^v 0^=>^ ... i . i , AA\.7yVVi clftfS? \ » (-$ • ' ';^-' S-* ^ \- I ' X fiA*Cc\s\A> i f\&J€.C\ , U6-T \l rvu - -4v\/y\C- Irl^C'l ? \\,CA UJ • J (X5) COMPLETION DATE \A £->/\SJ A. . C. r) I/^VC\ 5 ^J FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:7X8211 Facility ID: CA090000220 If continuation sheet Page 3 of 7 DEPARTMENT OF HEALTH AND HUM/ ^RVICES CENTERS FOR MEDICARE & MEDICAID bERVICES PRINTED: 01/03/2008 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 05G142 BWING 12/2'/2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA HOUSE 1768 MONTE MAR ROAD VISTA, CA 92084 (X4) ID PREFIX TAG W368 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 at 8 P.M. to prevent constipation." On 12/20/07 at 6:40 P.M. an interview with the <'"'•' i* • was conaucied. Thfc-.J.«,...,> ncknowledgcu mai she had been present during the observation of Client 1 receiving -educations on 12/17/07 at 8:48 P.M. She verified her observation that Client 1's medications had been administered in one medication cup and had all been swallowed by Client 1. She stated that the Genasyme and the Phillips MOM tabs should have been administered separately to Client 1 andT^ -hould have been instructed to chew them. 2. Client 3 was admitted to the facility with diagnoses that included**" __ per her client identification sheet. On 12/17/07 at 9:15 P.M., the house manager called Client 3 to the kitchen for a prescription dental paste called Dentagel. out the Dentagel on »_ toothbrush and ^T started to put it in tlT mouth. Client 1 was told to go to^. bathroom to brust "IT" 'seth with the medication. *"**""^ft the kitchen and went upstairs to^, bathroom. r^_jvas observed 24 seconds later as > ,,,-came out of the bathroom, withou* ^~ toothbrush, and headed back down the stairs to the kitchen and living room. On 12/20/07 at 12:00 P.M. Client 3's clinical record was reviewed. The physician's orders called for "Dentagel 1.1% GEL 56GM ZZ #1 (In Lieu of PREVIDENT 2 OZ GEL) After brushing apply to toothbrush and brush for one min then expectorate and rinse mouth 3 times per day." On 12/20/07 at 6:40 P.M. an interview with the ID PREFIX TAG W368 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:7X8211 Facility ID: CA090000220 If continuation sheet Page 4 of 7 DEPARTMENT OF HEALTH AND HUM, ^RVICES CENTERS FOR MEDICARE & MEDICAID btRVICES PRINTED: 01/03/2008 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER VISTA HOUSE (X4) ID PREFIX TAG W368 W487 (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: A. BUILDING 05G142 BWING STREET ADDRESS, CITY, STATE, ZIP CODE 1768 MONTE MAR ROAD VISTA, CA 92084 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From oaae 4 '- „ .- ~V-:,n, • . ~ "^ was conducted. She stated that she had observed the house manager administer the Dentagel and acknowledged that Client 3 returned from the bathroom less than one minute after starting to brush *"""?eth with Dentagel. The ~~~~__ — 'acknowledged that the house manager had not observed Client 3 brushing with the Dentagel and had not instructec' "~^_ ' ) brush with the Dentagjej for any particular amount of time. The t^T~ .stated that there was currently no program in effect to assure use of the Dentagel as it was ordered by the physician. 483.480(d)(4) DINING AREAS AND SERVICE The facility must assure that each client receives enough food. This STANDARD is not met as evidenced by: Based on observation, interview, and record review the facility failed to provide clients one of five planned categories of food (the protein items) that the menu listed as choices for a breakfast bar. Findings: On 12/19/07 at 7:15 A.M. the<~ _ ._ — stated that for breakfast Hie" six clients wouia oe having a breakfast bar for breakfast that day. Th9»/ stated that the breakfast bar consisted of items listed on the breakfast bar menu which was posted on the refrigerator. On 12/19/07 at 7:30 A.M. the house manager directed the placement of breakfast choices placed on the kitchen counter for the clients to ID PREFIX TAG W368 W487 (X3) DATE SURVEY COMPLETED 12/21/2007 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) fr C-( ^Qrtvdr &CC&C, t}\P&^ \>e&n Ve-\^&f\j[ct #A \f^nOA \t> f^li \ \ rr s ^•\0 v& (fc\C*&A &£* \ i r /^f -~vl£_ ^ bv^Jlu-'W'(J V t-^'Vr ij ** * 'I y3 \(ZZ>\Jv* • JJU^ \- £.- ^/C\ & W* vvXdx \^ \AJ> ^ _3 A"f) I \0^ ^V\^*^ ^^ C\y , 1 f^^D/oVioty ^eowtfea -\c\ \ fi \A/\I r * &>l/'iUv**^-? . A f. 1 1,0fl^CVC^-' vJt-GA . \.ctd f\~DJvi l V <y\ \c^ r r U-rr\/v » ACA fod (X5) COMPLETION DATE \\M\ot FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7X8211 Facility ID: CA090000220 If continuation sheet Page 5 of 7 DEPARTMENT OF HEALTH AND HUM. ^RVICES CENTERS FOR MEDICARE & MEDICAID bcRVICES PRINTED: 01/03/2008 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER VISTA HOUSE (X4) ID PREFIX TAG W487 (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: A. BUILDING 05G142 B'WING STREET ADDRESS, CITY, STATE, ZIP CODE 1768 MONTE MAR ROAD VISTA, CA 92084 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 5 choose from. All clients were observed approaching the counter and selecting the items that they wanted to eat for breakfast. Direct care staff (DCS 1) and the house manager assisted the clients to chose were offered. between multiple items that On 12/19/07 at 7:35 A.M. the breakfast bar menu that was posted on indicated that there the house refrigerator were five categories of food ' on the menu as follows: 1. Cereals (whole grain cold or hot cereal, both with milk), 2. Fresh fruits in season, 3. Protein (yogurt, hard boiled egg, or 1 slice of cheese), 4. Bread ( whole grain toast, English muffin, or small muffin), and, 5. Drinks (fruit juice and milk ) Clients were observed choosing cereal, a serving of mango or applesauce, a bread item, fruit juice (V-8) and milk. All clients also had coffee. No yogurt, egg or cheese was observed offered to the clients on the breakfast bar. After selecting their breakfast items all clients were assisted to sit by DCS 1 and the house manager, or sat down themselves and began to eat breakfast. On 12/19/07 at 7:50 A.M., after all clients were eating breakfast for five minutes, the. _ was interviewed regarding the breakfast selections. She stated that the breakfast bar allowed the clients to choose between items listed in each category on the breakfast bar menu. When asked whether the clients had received any choicp if items from the protein category the ... acknowledged that no items from that category had been offered to the clients. The | -proceeded to offer each client a serving of string cheese. Each client (6 of 6) indicated that they wanted cheese. Four of 6 clients were observed eating the cheese during the remainder ID PREFIX TAG W487 (X3) DATE SURVEY COMPLETED 12/21/2007 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:7X8211 Facility ID: CA090000220 If continuation sheet Page 6 of 7 DEPARTMENT OF HEALTH AND HUM, CERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 01/03/2008 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER VISTA HOUSE (X4) ID PREFIX TAG W487 (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER:A. BUILDING 05G142 B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 1768 MONTE MAR ROAD VISTA, CA 92084 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 6 of their breakfast. On 12/1 9/07 at 8:00 A.M. theV „" acknowledged that the clients should have been offered an item in the protein category at the breakfast bar. ID PREFIX TAG W487 (X3) DATE SURVEY COMPLETED 12/21/2007 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:7X8211 Facility ID: CA090000220 If continuation sheet Page 7 of 7 Department of Health and Human Service? Centers for Medicare & Medicaid Services Form Approved OMB NO. 0938-0390 Post-Certification Revisit Report Public reporting for this collection of information is estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing the burden, to CMS, Office of Financial Management, P.O. Box 26684, Baltimore, MD 21207; and to the Office of Management and Budget, Paperwork Reduction Project (0938-0390), Washington, D.C. 20503. (Y1) Provider/ Supplier /CLIA/ Identification Number 05G142 (Y2) Multiple Construction A. Building B. Wing Name of Facility VISTA HOUSE (Y3) Date of Revisit 1/21/2008 Street Address, City, State, Zip Code 1768 MONTE MAR ROAD VISTA, CA 92084 This report is completed by a qualified State surveyor for the Medicare, Medicaid and/or Clinical Laboratory Improvement Amendments program, to show those deficiencies previously reported on the CMS-2567, Statement of Deficiencies and Plan of Correction that have been corrected and the date such corrective action was accomplished. Each deficiency should be fully identified using either the regulation or LSC provision number and the identification prefix code previously shown on the CMS-2567 (prefix codes shown to the left of each requirement on the survey report form). (Y4) Item (YS) Date (Y4) Item (Y5) Date (Y4) Item (Y5) Date Correction Completed ID Prefix W0359 01/21/2008 Reg. # 483.460(h)(2) LSC Correction Completed ID Prefix Reg.# LSC Correction Completed ID Prefix Reg.# LSC Correction Completed ID Prefix Reg.# LSC Correction Completed ID Prefix Reg.# LSC Reviewed By Reviewed By State Agency Reviewed By Reviewed By CMSRO Followup to Survey Completed on: 12/21/2007 Correction Completed ID Prefix W0368 01/21/2008 Re9-# 483.460(k)(1) LSC Correction Completed ID Prefix Reg. # LSC Correction Completed ID Prefix Reg.# LSC Correction Completed ID Prefix Reg.# LSC Correction Completed ID Prefix Reg. # LSC -Datevy — ~t~~./ '"StSfttrtwe-ef-Swyeyefi — ^ojjwOt ^bmM L Correction Completed ID Prefix W0487 01/21/2008 Re9-# 483.480(d)(4) LSC Correction Completed ID Prefix Reg.# LSC Correction Completed ID Prefix Reg.# LSC Correction Completed ID Prefix Reg.# LSC Correction Completed ID Prefix Reg.# LSC \ n"~l~ 1~~ 'Bate;)&udcW^ $4^ Date: Signature of Surveyor: Date: Check for any Uncorrected Deficiencies. Was a Summary of Uncorrected Deficiencies (CMS-2567) Sent to the Facility? YES NO Form CMS - 2567B (9-92)Page 1 of 1 Event ID: 7X8212 PRINTED: 05/22/2007 FORM APPROVED California Department of Health Service STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: CA090000220 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETEDA. BUILDING B. WING 05/22/2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE VISTA HOUSE 1 768 MONTE MAR ROAD VISTA, CA 92084 (X4) ID PREFIX TAG B 000 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Initial Comments The following reflects the findings of the California Department of Health Services during an entity reported incident investigation. Complaint Number: CA001 12045 Category: Accidents Representing the Department of Health Services: Christine Reed, HFEN The inspection does not represent the findings of a full inspection of the facility. The department was unable to substantiate the allegation of a violation of the regulations. i i I I - ' I^A&K.^O^S/-' ID PREFIX TAG BOOO j V E PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) f n Hi i C i 1 ¥ ' i'- = iy/, Hi JUN 11 20Ct T i | y^^|3^if!^£ AS® CERT ,;" '.,,<- ! • S#V$ j^tttl^ffeBBiyiUWOi! OF" ' {- > (X5) COMPLETE DATE 5NA70RE" __ TITLE (X6)OATE STATE FORM ZO1M11 Ifcontintatiosheet' 1 of 1 DEPARTMENT OF HEALTH AND HUC ... SERVICES CENtERS FOR MEDICARE & MEDICAID SERVICES Printed: 02/09/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 05G142 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 02/02/2007 NAME OF PROVIDER OR SUPPLIER VISTA HOUSE STREET ADDRESS, CITY, STATE, ZIP CODE 1768 MONTE MAR ROAD VISTA, CA 92084 (X4)ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE wooo W 124 INITIAL COMMENTS The following reflects the findings of the Department of Health Services during a FUNDAMENTAL survey. Representing the Department of Health Services: Lee Woodin, HFEN. The census at the time of the survey was 6 clients. The sample size was 3 clients. 483.420(a)(2) PROTECTION OF CLIENTS RIGHTS The facility must ensure the rights of all clients. Therefore the facility must inform each client, parent (if the client is a minor), or legal guardian, of the client's medical condition, developmental and behavioral status, attendant risks of treatment, and of the right to refuse treatment. This Standard is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure that there were current consents in place for 2 of 3 sampled clients (1,3). As a result, there was no current consent for Client 3's medication used to control behaviors and no current consents for the use of door alarms, locked knives and cleaning supplies for Client 1. Findings: 1. Client 1 was admitted to the facility with diagnoses that included ^_ WOOO W124 LICENSING AN SAN D!EGO DISTRICT OFFICE SO JTH .and' ^ per the face sheet. On 1/30/07 at 3:45 P.M. obeservations revealed that a chime sounded each time the front door of the facility opened. Additional observations LABORAT (X6) DATEECTOR'S OR/PROVIDER/^UPPLIER REPRESENTATIVE'S SIGNATURE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be,4xcused from correcting providing it is deteimmedthat other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing hernes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete 7GRN11 If continuation sheet Page 1 of 11 DEPARTMENT OF HEALTH AND HUk > SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Printed: 02/09/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . Rimn,Mr COMPLETEDA. BUILDING 05G142 BWING 02/02/2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA HOUSE 1 768 MONTE MAR ROAD VISTA, CA 92084 (X4) ID PREFIX TAG W124 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 revealed that knives were kept in a locked drawer in the kitchen and all cleaning supplies were kept in a locked cupboard. On 1/30/07 at 4:45 P.M. Client 1 was awake, alert and independently ambulating through the kitchen and family room area. On 1/31/07 at 6:50 A.M. Client 1 ambulated tojhe kitchen. The client independently served '""' "~* yoghurt, cold cereal, juice and coffee. After eating, the client emptied the dishwasher and put the clean dishes and utensils in drawers and cupboards. There were no knives in the dishwasher or in the drawer with other eating utensils. On 2/01/07 at 8:00 A.M. an review of Client 1's record was initiated. Record review revealed copies of consents for the use of door alarms, locked knives and cleaning supplies. The consents were unsigned. A handwritten note in the upper right corner indicated that consents were sent to family for signature on 1 1/18/04. There was no evidence of the return of the signed documents. On 2/01/07 at 1:50 P.M. an interview was conducted with the* ____. — ^ j_j * (QMRP). The*, acknowledged that Client 1 had no signed consents in place. 2. Client 3 was admitted to the facility with diagnoses that inrli irtei* r ' vithT, — . fjer the face sheet. On 1/30/07 at 4:00 P.M Client 3 returned to the facility from day program. The client was alert, ambulatory and able communicate verbally. ID PREFIX TAG W 124 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) C-<x**&3*> wev^. *.<yxX/vtA r . 1 f /-\v -\£ ^A~" 4 i 'T*"H*'tj °t »e*~ <**• 'i\^lrl •~""Tk«- ' l-S r£speiA^v>|e -ft, evA-VtA^ oov^-t* *v^oM*iA- <X5) COMPLETION DATE , 3!jtrz- 07 } FORM CMS-2567(02-99) Previous Versions Obsolete 7GRN11 If continuation jheeLEage_-2-of-4J DEPARTMENT OF HEALTH AND HUk. ..4 SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Printed: 02/09/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER VISTA HOUSE (X4) ID PREFIX TAG W 124 W183 (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: A BLMLD|NG 05G142 BWING STREET ADDRESS, CITY, STATE, ZIP CODE 1768 MONTE MAR ROAD VISTA, CA 92084 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 On 2/01/07 at 10:40 A.M. a review of Client 3's record was conducted. The 8/24/06 annual Individual Service Plan (ISP) identified 2 behavioral goals. The client had goals to decrease tantrum build up behaviors as well as tantrums. According to the plan, if behavioral interventions did notjnelp the clientta calm down, a' __ vas needed)', f* -j^and i " • —~) 25 mg was to be given. Further recojd review revealed a consent for the use of t» '.^ handwritten note in ..:e consent was unsigned. A the upper right hand corner indicated that the consent was sent to the family for signature on 1/15/06. There was no evidence of the return of the On 2/01/07 at 1:50 conducted with the signed consent. P.M. an interview wgs. —— -— — — • XQMRP). Thb-^ .rdcknowledged that unent 3 had no signed consent in place for _. 483.430(c)(2) FACILITY STAFFING There must be responsible direct care staff on duty and awake on a 24-hour basis, when clients are present, to take prompt, appropriate action in case of injury, illness, fire or other emergency, in each defined residential living unit housing: (i) Clients for whom a physician has ordered a medical care plan; (ii) Clients who are aggressive, assaultive or security risks; (iii) More than 16 clients; or (iv) Fewer than 16 clients within a multi-unit building. This Standard is not met as evidenced by: ID PREFIX TAG W124 W183 (X3) DATE SURVEY COMPLETED 02/02/2007 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 4\\#« YYicuu OCC*A( $3~"i\c<A.v\ i (\w \e£>&&r>&\£>\ \( TV- -f» M^£ uC^^ 4t? 5W*9\c-WTtfv\ » »MLt> .^n^H^ AA\ A I G'f *YA^&- flfi (),{£&}(.£- (XS) COMPLETION nATFUri 1 C ?<*07 <_ 3l£?3,Uri 1 ^ DEPARTMENT OF HEALTH AND HU. ..k SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Printed: 02/09/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 05G142 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY A. BUILDING COMPLETED B. WING 02/02/2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA HOUSE 1 768 MONTE MAR ROAD VISTA, CA 92084 (X4) ID PREFIX TAG W 183 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 Based on observation, interview and record review, the facility failed to ensure that responsible direct care staff were awake and on duty when clients were present. As a result, clients with _^_ ' .' ~" . ~^_ L and self-injurious behaviors were not supervised during overnight shifts. Findings: On 1/30/07 at 3:00 P.M. observations revealed that the facility was 3 levels. Bedrooms were on the first and third level. The front door was on the second level. The garage and an exit door was located on the first level. A chime sounded each time the front door opened. There were wall mounted electronic movement senors on each level. On 1/30/07 at 3:10 P.M. Direct Care Staff (DCS) 2 stated during interview that she lived at the facility in separate quarters on the third level. DCS 2 stated that from 9:00 P.M. to 6:30 A.M. she was the only staff present in the facility. DCS 2 stated that she slept during her shift and there was no requirement or expectation that she remain awake to supervise clients. During evening observations on 1/30/07 from 3:15 P.M. to 9:00 P.M. all 6 clients were ambulatory. The clients were observed to access drawers, cupboards and closets independently. Additionally, the clients were observed to independently enter the garage. On 2/01/07 at 7:10 A.M. a review of client records was initiated. 1a. Client 1 was admitted to the facility with diagnoses that include^ "-• " — *~ ;>er the face sheet. The 1 2/1 9/06 annual Individual Service Plan (ISP) indicated ID PREFIX TAG W183 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) r * V^S-o/to £?i\?\C- •v£^£nS>W'<<i| ^~ ~ * ' v_ ^P?<C> P^^"^ £"Z5C^"H*^3 G\i«b. (X5) COMPLETION DATE •»<5\ J < ltcontinuatlon-sbeetEage-4-oM4-- DEPARTMENT OF HEALTH AND HU. .,N| SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Printed: 02/09/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER VISTA HOUSE (X4) ID PREFIX TAG W 183 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 05G142 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 02/02/2007 STREET ADDRESS, CITY, STATE, ZIP CODE 1768 MONTE MAR ROAD VISTA, CA 92084 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 that the client had 1 ' j and inappropriate attention seeking behaviors. Additionally per a 10/03 Cover Sheet,the client had a history of leaving the facility without permission. 1 b. Client 2 was admitted to the facility with diagnoses that included tt_^__ ' L, *™" "•"•• • -r,(j f oer the face sheet. The 11/14/06 annual Individual Service Plan (ISP) indicated that the client had inappropriate bathroom behaviors. 1c. Client 3 was admitted to the facility with diagnoses that incli **^~^—- •— jded ^-•^^^••fc and " "*•• oer the face sheet. The 8/24/06 Individuaj^ervce Plan (ISP) indicated that the client had""™"^* behaviors that could excalate to the point an < 5dication was needed. Additionally the client was physically aggressive and exhibited property destructive behaviors. 1d. Client 4 was admitted to the facility with diagnoses that includec' ~"^^—— *^**ll [ ~~ r3r the face sheet. The 11/1 4/06 Individual Service Plan (ISP) indicated that the client har — ^m**m •*property destruction and elopement behaviors. Additionally per a 10/21/99 Cover Sheet, the client had a "long history" of negative behaviors to gain attention. Per the document, the client would leave the facility without permission. Staff were ensure that the house alarm was set on "stay" at all times so that an alarm would sound when a door was opened. Additionally,the client would use a telephone to call "91 1 ." Staff were to ensure that the facility phone and any personal phones were secured at all times to prevent client's access to them. ID PREFIX TAG W 183 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION rtATPUM 1 II FORM CMS-7GRMlt If .continuation, sheet Pag»5-Q{44 DEPARTMENT OF HEALTH AND HU, A SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Printed: 02/09/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER VISTA HOUSE (X4) ID PREFIX TAG W 183 W252 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 05G142 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 02/02/2007 STREET ADDRESS, CITY, STATE, ZIP CODE 1768 MONTE MAR ROAD VISTA, CA 92084 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From pa 1e. Client 5 was ac diagnoses that inck ^tZL^— genera age 5 Imitted to the facility jded f ~U6 izedi ~tt "%perthe face sh 1/17/07 Individual Service Plan (ISP) inc that the client had inappropriate attentio aggressive tantrum behaviors, self injur property destruction behaviors. 1f. Client 6 was admitted to the facility \ diagnoses that includetft,^^.— m^-^ — - •» ' ^&na reaction per the fac Individual Service F client had self injuri cutting self with sci behaviors (eating n the client would ing other non food item closely." On 2/01/07 at 2:55 conducted with the with rand eet. The Jicated n seeking, ous and with -iH e sheet. The 7/2 1/06 Man (ISP) indicated that the ous behaviors to include ssors or knives and-~~~ on-food items). Per the plan, est coins, paper clips and s and "must be monitored P.M. an interview was that all of the clients at the facility had , s°h*»«/iro tnat required sta monitoring. The . ~_.ifirmed that no staff awake and on duty during the o shifts. 483.440(e)(1) PROGRAM DOCUMENT Data relative to accomplishment of the < specified in client individual program pla objectives must be documented in mea terms. lowledged ff there was vernight ATION ;riteria n surable ID PREFIX TAG W183 W252 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE FORM CMS-2567(02-99) Previous Versions Obsolete 7GRN11 If continuation sheet Page 6 of 11 DEPARTMENT OF HEALTH AND HU,. .d SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Printed: 02/09/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A Rl ,,. „...- COMPLETEDA. BUILDING 05G142 BWING 02/02i/2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA HOUSE 1768 MONTE MAR ROAD VISTA, CA 92084 (X4) ID PREFIX TAG W252 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 6 This Standard is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure that documentation related to a behavior management plan for 1 of 3 sampled clients (3) was accurate and meaningful. As result, the data necessary for monthly review of the program was incomplete. Findings: Client 3 was admitted to the facility with cliscjnosss thst inclu^^1^ ^... - f Her the face sheet. On 1/30/07 at 4:10 P.M. Client 3 was alert, verbal and independently ambulated throughout the facility. At 5:00 P.M., during an outing to a large store, the client became visibly agitated and "flapped" "H -irms repeatly. Direct Care Staff (DCS) 1 verbally prompted the client to calm down. At approximately 5:25 P.M. the client again began to flap<~ ms and rocktisck on forth on ~~ ..,^els. DCS 1 verbally prompter <— to calm down. On 2/01/07 at 10:40 A.M. a review of Client 3's record was conducted. Per a 7/10/03 physician order, Client 3 rece ved ' "_ " \ „ -" _ ^> 25 mg twice a day for agitation. Additionally, "the client could receive an additional 25 mg of ) as needed, not to exceed 4 doses in 24 hours. The 8/24/06 Individual Service Plan (ISP) identified goals for Client 3 to decrease tantrum build up behaviors and tantrum behaviors. Tantrum build up behaviors were identified as hand flapping, body rocking, hand wringing and non responsiveness to requests. If the client did ID PREFIX TAG W252 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION AT FORM CMS-2567(02-99) Previous Versions_ Obsolete 7GRN44-If eonttnuatavstieef Page-^7 of tt DEPARTMENT OF HEALTH AND Hb. <N SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Printed: 02/09/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING COMPLETED 05G142 BWING 02/02 /2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA HOUSE 1 768 MONTE MAR ROAD VISTA, CA 92084 (X4) ID PREFIX TAG W252 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 7 not display build up behaviors, ' .i/ould receive a piece of candy. If behaviors occurred, staff were to prompt the client to calm down and remove from the group to a quiet area as needed. Per the plan, if the client did not calm down after 10 minutes * '5 mg was to be given. Data was documented daily on number of occurrences, if candy was earned and if v 'was given. Tantrum behaviors were identified as 2 or more of the following behaviors: hitting, scratching others, screaming, pounding, stomping, head banging or biting/scratching self. If the client did not display build up behaviors, -ould receive a piece of candy. If behaviors occurred, staff were to prompt the client to calm down and remove from the group to a quiet area as needed. Per the plan, if the clientjJid not calm down after 10 minutes, • ^ .3 was to be given. Data was documented* dany un number of occurrences, if candy was earned and ifV_ - was given. Additionally, a narrative documentation of the incident was to be completed. A review of the data sheets for the tantrum build up and tantrum behaviors from May 2006 through January 2007 was conducted. Tantrum build up data was not consistently documented. There were multiple instances where documentation related to candy was missing. Additionally, there were was no documentation at all for 5/1 1/06, 5/1 2/06 and 8/25/06. Tantrum data sheets for May 2006 documented 2 episodes that required the administration of A Ithough there was a requirement to complete a narrative of each episode, only one was done. Additionally, there was no documentation at all for 5/1 1/06 and 5/12/06. June data sheets documented 4 episodes that ID PREFIX TAG W252 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE FORM CMS-2567(02-99) Previousyersjons_Obs_olete 7GRN44 — If^GFrtmuatiefv sheet-Page 8 tiftl DEPARTMENT OF HEALTH AND HU,. ,N SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Printed: 02/09/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BU|LD|NG COMPLETED 05G142 BWING 02/02/2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA HOUSE 1768 MONTE MAR ROAD VISTA, CA 92084 (X4) ID PREFIX TAG W252 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 8 required the use of* However, there was no narrative related to the episode on 6/05/06. July 2006 data sheets indicated 8 episodes but narratives were completed on only 7. August 2006 data sheets indicated 8 episodes but narratives were completed on only 7. Additionally, there was no documentation at all for 8/25/06 and 8/31/06. September 2006 data sheets documented 5 episodes but a narrative was completed on only one. On 2/01/07 at 3:10 P.M. an interview and joint record review was conducted with the ^ ~" '" ""•'"acknowledged that data was not W331 consistently documented for Client 3's behavior programs. The* " idrther stated that she used the data, on a monthly basis, to evaluate the success of the interventions and revise them as necessary. Additionally, the . jtated that although the current program did not require a narrative for tantrum build up behaviors, it would be valuable to track and monitor episodes that did not escalate to full tantrum behaviors. 483.460(c) NURSING SERVICES The facility must provide clients with nursing services in accordance with their needs. This Standard is not met as evidenced by: Based on interview and record review, the facility failed to ensure that 1 of 3 sampled clients (3) received health related services as ordered by the physician. As a result, the client had not had an annual i^ " screening since 2002 and an annual electrocardiogram ( EKG) since 2004. Findings: Client 3 was admitted to the facility with ID PREFIX TAG W252 W331 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Cli'evcV ^S do&uv**v-Tz4j«n- ^^• 1 t/v» j W*. ytnAeU-cd ^A ^'bf^ "H \ J <$l\»*J Ov^^W^" WAA^'»V 0*#i\ *• ' w-•Wii-Ct^ (vv ^W*- v*^*"^ f •f>"®*" JU ^uvr^M- A v^^W ^ Ux^ \*-J^^L ^ 'V*'*-*™* K"U . \ \ <>v^v;\7U K^^_, ? ^ vs <^*y Jf "t" b-mAJ-r <^6CAA.t^_«~-t•frw«iv^-«- j)-oa^^ J^U, o\.C*-C/•**• p (X5) COMPLETION HATPUf\\ C. »~1 »\^Vy. A/iAftv^ FORM CMS-2567(02-99) Previous yersion^ObspJete ZGRN-14- DEPARTMENT OF HEALTH AND HL ,vl SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Printed: 02/09/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 05G142 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 02/02/2007 NAME OF PROVIDER OR SUPPLIER VISTA HOUSE STREET ADDRESS, CITY, STATE, ZIP CODE 1768 MONTE MAR ROAD VISTA, CA 92084 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE W331 W371 Continued From page 9 diagnoses that i "wit1 W331 :>er the face sheet. On 2/01/07 at 10:40 A.M. a review of Client 3's record was initiated. Per 8/1 7/97 physician orders, Client 3 was to receive an annual JT_.._ T" >ancl EKG. The most recent dated 1 1/07/02 and the most ***** is recent EKG was dated 4/21/04. An interview was conducted with the facility nurse (RN) on 2/01/07 at 1:40 P.M. The RN confirmed that the physician orders for Client 3's annual EKG were current. The RN r-c. acknowledged that the client had not received services as ordered. 483.460(k)(4) DRUG ADMINISTRATION The system for drug administration must assure that clients are taught to administer their own medications if the interdisciplinary team determines that self-administration of medications is an appropriate objective, and if the physician does not specify otherwise. This Standard is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure that 1 of 3 sampled clients (3) Individual Service Plan (ISP) did not include a goal to increase'lvokills related to medication administration. As a result, the client did not participate to the best ofll abilities. Findings: Client 3 was admitted to the facility with diagnoses that included W371 FORM CMS-2567(02-99) Previous Versions Obsolete 7GRN11 If continuation sheet Page lQ-ofJ4 DEPARTMENT OF HEALTH AND HU; ,vl SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Printed: 02/09/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 05G142 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY A. BUILDING COMPLETED B. WING 02/02/2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA HOUSE 1 768 MONTE MAR ROAD VISTA, CA 92084 (X4) ID PREFIX TAG W371 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 10 On 1/30/07 at 4:00 P.M. Client 3 returned to the facility from day program. The client was alert and able to communicate verbally. The client was independently ambulatory. At 4:35 P.M. a medication administration observation was conducted. Client 3 independently got a glass of water from the kitchen sink. The client then ambulated to the family room and sat in a chair beside the desk. Direct care Starr (DCS) 1 placed 1____^- paper cup and gave the cup to the client. The medication was not identified nor were the indications or side effects discussed with the client. The client tipped the medication '"« mouth and swallowed with a sip of water. The client then independently threw away the cup. On 2/01/07 at 10:40 A.M. a review of Client 3's record was initiated. The 8/24/06 annual Individual Service Plan (ISP) did not address the client's abilities related to medication administration. The ISP did not include a goal to provide training to increase Client 3's participation in ',^1 Dedication regimen. An interview, was ™">nrli irtprj with thff 2/01/07 at 2:25 P.M. Th \ ' acknowledged that Client 3's ISP did not include a medication administration goal. TheT -stated that a medication related goal "had been missed" and that Client 3 would benefit from the additional training. ID PREFIX TAG W371 / PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) CliwV *^ w^s ^tct^U V<4- fiUv ^ VwtX-4A^A X/JW-A-C- <<Uj.s. v-j^s <^ic*s.<nj,d. c-l'«~4"3 tAiill \K_ VO-OC\£-,A^\ «w^ ^- ^^^ ^ JL+> iD •r- - Mro^, v—is. ~~~" \ '"VV*- ID •V-Otfot^v &~-eA ^(>*<^«4««J vi — - — » ;« r-t-sp-^w^jVU. H-\w, •"•" s r ^v ^ ^w. c^^^^'< ^ dbtsAt ^~^ &^\f^<^*-) yrls JP ^— ' (X5) COMPLETION DATE ?('vc? ^ FORM CMS-2567(02-99) Previous Versions Qb_sojete __7GRN41 If contouatien sheet Page 1-1-eH-l-— Department of Health and Human Servic Centers for Medicare & Medicaid Service Form Approved OMB NO. 0938-0390 Post-Certification Revisit Report Public reporting for this collection of information is estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing the burden, to CMS, Office of Financial Management, P.O. Box 26684, Baltimore, MD 21207; and to the Office of Management and Budget, Paperwork Reduction Project (0938-0390), Washington, D.C. 20503. (Y1 ) Provider / Supplier / CLIA / Identification Number 05G142 (Y2) Multiple Construction A. Building B. Wing Name of Facility VISTA HOUSE (Y3) Date of Revisit 2/8/2007 Street Address, City, State, Zip Code 1768 MONTE MAR ROAD VISTA, CA 92084 This report is completed by a qualified State surveyor for the Medicare, Medicaid and/or Clinical Laboratory Improvement Amendments program, to show those deficiencies previously reported on the CMS-2567, Statement of Deficiencies and Plan of Correction that have been corrected and the date such corrective action was accomplished. Each deficiency should be fully identified usin requirement on the survey report form). (Y4) item (Y5) Date (Y4) Item (Y5) Date (Y4) Item (Y5) Date Correction Completed ID Prefix W0124 03/02/2007 Reg. # 483.420(a)(2) LSC Correction Completed ID Prefix W0331 03/02/2007 Reg. # 483.460(c) LSC Correction Completed ID Prefix Reg.# LSC Correction Completed ID Prefix Reg.# LSC Correction Completed ID Prefix Reg.# LSC ^ -\ RevTewecf By^ ^^^ ~5^*j£jSp?^Vs// State Agency CjJ^C^l/^l^^yj7^"^ Revi&wed By RevJGWtKvSyr ,*~s CMSRO Followup to Survey Completed on: 2/2/2007 Correction Completed ID Prefix W0183 03/02/2007 Reg.# 483.430(c)(2) LSC Correction Completed ID Prefix W0371 03/02/2007 Reg. # 483.46000(4) LSC Correction Completed ID Prefix Reg.# LSC Correction Completed ID Prefix Reg.# LSC Correction Completed ID Prefix Reg.# LSC •? y: ^)J s^T^r* \Dato:J&>/ Signatufe-o^ryeyoV^:}^&(o^^f^L^L ID Prefix W0252 Correction Completed 03/02/2007 Reg. # 483.44o(e)cn LSC ID Prefix Correction Completed Reg.# LSC ID Prefix Correction io;- Completed' Reg.# LSC ID Prefix Correction Completed Reg.# LSC ID Prefix Correction Completed Reg.# LSC ' ^\ 2^>W Date: Signature of SurveyoriN. // ^7Check for any Unconnected Deficie Uncorrected Deficiencies (CMS ncies. Was a Summary of -2567) Sent to the Facility? Date: / , J>^^7Da&: ^ ' YES NO Form CMS - 2567B (9-92)Page 1 of 1 Event ID: 7GRN12 State 01 ^dlifornia—Health and Human Serviced Agency Department of Health Services CaliforniaDepartment of Health Services Sandra Shewry . ARNOLD SCHWARZENEGGER Director ' GOVERNOR Dear: An exit conference has been conducted regarding deficiencies found during a visit to this facility to determine compliance with state licensing regulations or federal requirements for certification as a provider/supplier of health care services. The plan of correction for each deficiency listed must contain the following: A. How the correction will be accomplished, both temporarily and permanently; B. The title or position of the person responsible for correction; C. Description of the monitoring process to prevent recurrence of the deficiency; . .. ... .. .. ... . D. Date the immediate correction of the deficiency will be accomplished. Normally this will be no more than thirty (30) days from the date of the exit conference. However, in the case of civil money penalties (citations) being issued, the correction of the deficiency may be required to begin immediately with all correction of the deficiency being completed in less than thirty (30) days. If the plan of correction is not acceptable to the Department, you will be notified and requested to provide a more specific plan. If necessary, an informal conference will be held to obtain a satisfactory plan of correction. A rebuttal of the deficiency is not a plan of correction. California Health and Safety Code, Section 1280, requires a plan of correction for all deficiencies. By providing a plan of correction, a licensee or designee does not necessarily admit guilt of any alleged violation nor does this interfere with the right to contest or appeal any alleged violations. If you disagree with any deficiency, you must request, in writing (on the 2567, if you desire), an informal conference with the District Administrator of this office, but a plan of correction must be given for all deficiencies. Do your part to help California save energy. To learn more about saving energy, visit the following web site: www.consumerenergycenter.org/flex/index.html Licensing and Certification, San Diego District Office South, 7575 Metropolitan Drive, Suite 211, San Diego, CA 92108 (619)688-6190 Fax (619) 688-6444 Internet Address: www.dns.Ga.gov t-AX fbO 121 3872 TERI, Inc.1^001/031 LICENSING AND CERTIFICATION SAN D|EG(j DISTRICT OFFICE 251 Airport Road * Oceanside • CA 92054 (760) 721-1706 • (760) 721-9872 fox • www.teriinc.org Founded in 1980 in San Diego, TERI, a private, non-profit 50l(C)(3) corporation, is dedicated to offering a wide range of services and programs supporting individuals of all ages with developmental and learning disabilities and their families. As a major component in this effort, TERI has conceived the Center for Research &£ Life Planning, a new campus, to be located in the Twin Oaks Valley area of San Marcos, consolidating TERI's educational, research, therapeutic, training, vocational, and recreational programs into one site. For more information on how you can get involved with TERI and the Center for Research &c Life Planning, please caJl Cheryl Kilmer at (760) 721-1706. Fax Cover Sheet Attn: From: "fe«fe Fax#: A.Date: Pages: 3|. (including this sheet) Comments: rtatementr This message is intended only for the use of the individual or entity to which it is addressed and may contain information that is privileged, confidential or exempt from disclosure under applicable Federal or State law. If the reader of this message is not die intended recipient, you are hereby notified dm any dissemination, distribution or copying of this communication is strictly prohibited. If you have received this communication in error, please notify us immediately by telephone and return the original message to us at the address above. 03/09/2007 19:28 FAX 760 721 9872 TERI, Inc.@001/012 TER! TRAINING EDUCATION ^RESEARCH INS 251 Airport Road • Oceanside • CA 92054 (760) 721-1706 • (760) 721-9872 fax • www.teriinc.org Founded in 1980 in San Diego, TERI, a private, non-profit 501(C)(3) corporation, is dedicated to offering a wide range of services and programs supporting individuals of all ages with developmental and learning disabilities and their families. As a major component in this effort, TERI has conceived the Center for Research & Life Planning, a new campus, to be located in the Twin Oaks Valley area of San Marcos, consolidating TERI's educational, research, therapeutic, training, vocational, and recreational programs into one site. For more information on how you can get involved with TERI and the Center for Research & Life Planning, please call Cheryl Kilmer at (760) 721-1706. Fax Cover Sheet Arm: From: Fax#: Hinw&Date: Pages: (including this sheet) Comments: Privacy Statement: This message is intended only for the use of the individual or entity to which it is addressed and may contain information that is privileged, confidential or exempt from disclosure under applicable Federal or State law. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited- If you have received this communication in error, please notify us immediately hy telephone and return the original message to us at the address above. 03/09/2007 13 28 FAX 760 721 9872 TERJ, Inc.) 002/012 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Printed: 02/09/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER VISTA HOUSE (X4) ID PREFIX TAG wooo W 124 (X1) PROVIDER/SUPPLIER/CLJA IDENTIFICATION NUMBER: 05G142 (X2) MULTIPLE CONSTRUCTION A, BUILDING B. WING (X3) DATE SURVEY COMPLETED 02/02/2007 STREET ADDRESS. CITY. STATE. ZIP CODE 1768 MONTE MAR ROAD VISTA, CA 92084 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) INITIAL COMMENTS Tha following reflects the findings of the Department of Health Services during a FUNDAMENTAL survey. Representing the Department of Health Lee Woodin. HFEN Services: The census at the time of the survey was 6 clients. The sample size was 3 clients. 483.420(a)(2) PROTECTION OF CLIENTS RIGHTS The facility must ensure the rights of all clients. Therefore the facility must inform each client. parent (if the client is a minor), or legal guardian, of the client's medical condition, developmental and behavioral status, attendant risks of i treatment, and of the right to refuse treatment. ' This Standard is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure that there were current consents in place for 2 of 3 sampled clients (1,3). As a result, there was no current consent for Client 3's medication used to control behaviors and no current consents for the use of door alarms, locked knives and cleaning supplies for Client 1. Findings: 1 . Client 1 was admitted to thaJacilitv^/ith diagnoses that includedff ,.., ^ •" -^v=i u ic face sheet. On 1/30/07 at 3:45 P.M. obeservations revealed that a chime sounded each time the front door of the facility opened.Additional observations ID PREFIX TAG wooo W 124 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (Xi) COMPLETION OATPUH I C LABORATORY OlRECTOR'S ORpROVlDER/gPPLIER REPRESENTATIVE'S SIGNATURE (XS)DATE Any deficiency statement ending with an asterisk (") denotes a deficiency which the Institution may beAxcused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing hernes, (he findings stated above are dlsclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable n days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete 7GRN11 If continuation sn»el Page 1 of 11 o :j / o a / 2 o 01 i y 2 a i- A x t b o I y «itKi, me 003/0 ) 1 DEPARTMENT OF HEALTH AND HUMAN SERVIQES CENTERS FOR MEDICARE & MEDICAID SERVIfJES STATEMENT OF DEFICIENCIES (X1) PROVlDER/SUPPUER/QLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BU|LD,NG 05G142 B W1NG NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE. ZIP CODE VISTA HOUSE 1768 MONTE MAR ROAD VISTA, CA 92084 (X4) ID PREFIX TAG W 124 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 revealed that knives were kept in a locked drawer in the kitchen and all cleaning supplies were kept in a locked cupboard. On 1/30/07 at 4:45 P.M. Client 1 was awake, alert and independently ambulating through the kitchen and family room area. On 1/31/07 at 6:50 A.M. Client 1 ambulated to the kitchen. The client independently served _ "* yoghurt, cold cereal, juice and coffee. After eating, the client emptied the dishwasher and put the clean dishes and utensils in drawers and cupboards. There were no knives in the dishwasher or in the drawer with other eating utensils. On 2/01/07 at 8:00 A.M. an review of Client 1's record was initiated. Record review revealed copies of consents for the use of door alarms, locked knives and cleaning supplies. The consents were unsigned. A handwritten note in Ihe upper right corner Indicated that consents were sent to family for signature on 1 1/1 8/04. There was no evidence of the return of the signed documents. On 2/01/07 at 1:50 P.M. an interview was ID PREFIX TAG W 124 - rnnrliirt^ With th°' -: : " that Client 1 had no signed consents in place. 2. Client 3 was admitted to the facility with diagnoses that included P~ "' [ * *S Jwirh f — •) per the face sheet. On 1/30/07 at 4:00 P.M Client 3 returned to the facility from day program. The client was alert, ambulatory and able communicate verbally. Printed: 02/09/2007 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED 02/02/2007 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) L . r • i r f \ \ •V-tJ"1 I 1- _l_« ,~l t* r II. r* ^ - 1 HK*«L.l<A TO T*»M-«IU OT UH-W MSJITJ _ — -"ft^. \3 r<TSp»v~t^ > e^W-t cov-^t* ^ ' •v* | l w>— — • - W [ ^ OWT^*'S^ (XS) COMPLETION DATE I C72- 07 I FORM CMS-2567(02-99) Prewleue VftrslOB&Obsslftte--7GRN-H--i' cQpilnuaton sheeLPaoe. 2jrf.ll_ > o / '.,' -I / <: ','',' f I 3 . i ti 1- ft A 38 \ tin, inc DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES &) 004/0 12 Printed: 02/09/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER VISTA HOUSE (X4) ID PREFIX TAG W 124 (XI) PROVIDERySUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: A BU|LD|NC; 05G142 B-WING STREET ADDRESS, CITY, STATE. ZIP CODE 1768 MONTE MAR ROAD VISTA, CA 92084 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR L.SC IDENTIFYING INFORMATION) Continued From page 2 On 2/01/07 at 10:40 A.M. a review of Client 3's record was conducted. The 8/24/06 annual Individual Service Plan (ISP) identified 2 behavioral goals. The client had goals to decrease tantrum build up behaviors as well as tantrums. According to the plan, if behavioral interventions did not help the_cjient to calm down, a{~~ (as needed) W183 doser'w""^-J ^ — ™*rwas to be aiven. Furtherrecord review revealed a consent for the Mgpnf^ _„. The consent was unsigned. A handwritten note in the upper right hand corner indicated that the consent was sent to the family for signature on 1/15/06. There was no evidence of the return of the signed consent. On 2/01/07 at 1:50 conducted with the— • P.M. an interview was ~~ The*=r— I- t:knowledged that Client 3 had no signed consent in place for the use of "•"• 483.430(c)(2) FACILITY STAFFING There must be responsible direct care staff on duty and awake on a 24-hour basis, when clients are present, to take prompt, appropriate action in case of injury, illness, fire or other emergency, in each defined residential living unit housing: (i) Clients for whom a physician has ordered a' medical care plan; (ii) Clients who are aggressive, assaultive or security risks; (jii) More than 16 clients; or (iv) Fewer than 16 building. clients within a multi-unit This Standard is not met as evidenced by: ID PREFIX TAG W 124 W183 (X3j DATE SURVEY COMPLETED 02/02/2007 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) C^^T V>«, v^U •U 2] 0-7 ^c, £1^;°-^*i^\ o**- | ( af c\\i*Jh&-3- ~TV-x_ ' . J<> r-cs&-v- .W cMa^Va c~v^h3 v -VV-*-, &**• «-«-"VV^'T^> ^ CM&C^V?^ ^>TUr4- bfz, Q\ 4- A \ \A/"U\ A^LA f^C-VuTO CAdXV v»H. tA, iA 4VirtA" O1CUA OC6</(rr^~AL<A, ) r LjJ •4ryja Off. O^JX^C O~r ' M ^) . , . ,.\ -rC. \Nlo\e5o<9n6>^to\\iTV|. 4-r \nc -Wo *>Liv\>\&?(\&*^ ~uiu±>.5n \» i (\J\A Ifff ^OA^C- ^ &\&k-£- OYc^'fMA^T' ^-^^ d^~^ ^V <t *\***\ *\'T\^A\v^CAtA^, ^ \/lC' CA^) 3' _t UlA ' V^^VJC ^ e^A-4 ) - Tfc-OoJ' avVx^^c- c<Kiv\• \r\-t o*A t> Oe«i^ y» ^n-f-T - t>Ue r\ • 1X6) COMPLETIONf\*yrUAI C JlHo7' I / 3^oa.Un FORM CMS-2567(02-9911 Previous Versions Obsolete 7GRN-I1--I' conllnualion sheet Paga- 3 of U r D u f £a a t <;me .l 005/012 DEPARTMENT OF HEALTH AND HUviAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Printed: 02/09/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION PROV1DEFUSUPPLIER/CLIA IDENTIFICATION NUMBER: 05G142 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING . (X3) DATE SURVEY COMPLETED 02/02/2007 NAME OF PROVIDER OR SUPPLIER VISTA HOUSE STREET ADDRESS, CITY, STATE, ZIP CODE 1768 MONTE MAR ROAD VISTA, CA 92084 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS)COMPLETIONDATE W 183 Continued From page 3 Based on observation, interview and record review, the facility failed to ensure that responsible direct care staff were awake and on duty when clients were present. As a result, clients with aggressive, assaultive, elopement and self-injurious behaviors were not supervised during overnight shifts. Findings: On 1/30/07 at 3:00 P.M. observations revealed that the facility was 3 levels. Bedrooms were on the first and third level. The front door was on the second level. The garage and an exit door was located on the first level. A chime sounded each time the front door opened. There were wall mounted electronic movement senors on each level. On 1/30/07 at 3:10 P.M. Direct Care Staff (DCS) 2 stated during interview that she lived at the facility in separate quarters on the third level. DCS 2 stated that from 9:00 P.M. to 6:30 A.M. she was the only staff present in the facility. DCS 2 stated that she slept during her shift and there was no requirement or expectation that she remain awake to supervise clients. During evening observations on 1/30/07 from 3:15 P.M. to 9:00 P.M. all 6 clients were ambulatory. The clients were observed to access drawers, cupboards and closets independently. Additionally, the clients were observed to independently enter the garage. On 2/01/07 at 7:10 A.M. a review of client records was initiated. 1a. Client 1 was admitted tojhejacility with diaanoses that included (jCT~ "~ '.. _Apar the face sh ^i. The T2/ is/no annual Individual Service Plan (ISP) indicated W183 \ FORM CMS-25_67(02-991 .Prayious VersionsJDbSQlele_..7GRN-U _____________________________ if coniin 4_of 1L I-AX 760 721 3872 TERI, Inc.006/012 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Printed: 02/09/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER VISTA HOUSE (X*) 10 PREFIX TAG W 183 (X1) PROVIDER/SUPPLIER/CL1A IDENTIFICATION NUMBER: 05G142 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 02/02/2007 STREET ADDRESS. CITY, STATE, ZIP CODE 1768 MONTE MAR ROAD VISTA, CA 92084 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 that the client haaj11 '" -> , — f." 10/03 Cover sneer. __ ~ •-*- and*»—— <__ • _O Additionally per a me client had a history of leaving the facility without permission. 1 b. Client 2 was admitted to the facility with ci oer the face sheet. The 11/14/06 annual Individual Service Plan (ISP) indicated that the client had' ^ 1c. Client 3 was admitted to the facility with diagnoses that inck" •• , • - - • "••- ft •''.-. ' .,. jdedA— SB=—r rwith ^~ 'and1- ~ oerthe race sheet. ^he 8/24/06 Individual Service Plan (ISP) indicated that the client had tantrum behaviors that could excalate to the point an _ • * L [ impftiratinn was needed. A-uuionaiiy the client was physically aggressive and exhibited property destructive behaviors. 1d. Client 4 was admitted to the facility with diagnoses that include<. * • *oer the face sheet. The1 1/14/06 Individual Service Plan (ISP) indicated that the client had tantrum, aggression, assaultive, property destruction and elopement behaviors. Additionally per a 10/21/99 Cover Sheet, the client had a "long history" of negative behaviors to gain attention. Per the document, the client would leave the facility without permission. Staff were ensure that the house alarrrrwas set on "stay" at all times so that an alarm would sound when a door was opened. Additionally, the client would use a telephone to call "91 1 ." Staff were to ensure that the facility phone and any personal phones were secured at all times to prevent client's access to them. ID PREFIX TAG W 183 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (M) COMPLETION ircpnUnuillpn «rift«tPaj! ^5 of 11 o / u a / £ <> <..> i i a ,-' 3 r« A r b u 12 i y a (2 ibHi, inc.0007/012 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Printed: 02/09/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER VISTA HOUSE (X4)ID PREFIX TAG W 183 1 W252 (X1) PROV1DER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: A BU|LDING 05G142 B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 1768 MONTE MAR ROAD VISTA, CA 92084 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 5 1e. Client 5 was admitted to the facility with ^diagnoses that included *~r_^... ••, _ - -• rand fe per the face sheet. The T/f7/07 Individual Service Plan (ISP) indicated that the client had af '^\_<tr~ \r *>. property destruction behaviors. 1 f. Client 6 was admitted to the facility with diagnoses that includedjp """"* "^ f~~~ •••• . r^ • • v T" •* — — A-— » - per the face sheet. The 7/21/06 Individual Service Plan (ISP) indicated that the client had self injurious behaviors to include cutting self with scissors or knives andjBP* behaviors (eating non-food items). Per the plan, the client would ingest coins, paperclips and other non food items and "must beVnonitored closely." ^ On 2/01/07 at 2:55 P.M. an interview was conducted with the^S . , _. wrnrn* that all of the clients at the facility had f* " __ ~ . •> behaviors that required staff monitoring. The no staff awake and shifts. . .^nfirmed that there was on duty during the overnight 483.440(e)(1) PROGRAM DOCUMENTATION Data relative to accomplishment of the criteria specified in client individual program plan objectives must be documented in measurable terms. ID PREFIX TAG W183 W252 (X3) DATE SURVEY COMPLETED 02/02/2007 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 1X5) COMPLETION DATE 7GRN14 4tconlinu81ton-3h*ei- Page- 6 eM-1— 11 ni, inc.'•) '•> a /') DEPARTMENT OF HEALTH AND Hu-viAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Printed: 02/09/2007 FORM APPROVED OMB NO. 0936-0391 STATEMENT OP DEFICIENCIES (XI) PROVIDER/SUPPUER/CLIA AND PLAN OF CORRECTION IDENTIFICATION! NUMBER; 05G142 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY A. BUILDING COMPLETED 6. WING U210t!/2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA HOUSE 1768 MONTE MAR ROAD VISTA, CA 92084 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) W252 Continued From page 6 This Standard is not met as evidenced by: Based on observation, interview and record review, the facility railed to ensure that documentation related to a behavior management plan for 1 of 3 sampled clients (3) was accurate and meaningful. As result, the data necessary for monthly review of the program was incomplete. Findings: Client 3 was admitted to the facility with diagnoses that included " , i <r and1" ~ + On 1/30/07 at 4:10 P.M, Client 3 was alert, verbal and independently ambulated throughout the facility. At 5:00 P.M., during an outing to a large store, the client became visibly agitated and "flapped"*.. rms repeatly. Direct Care Staff (DCS) 1 verbally prompted the client to calm down. At approximately 5:25 P.M. the client again began to flap ^? arms and rock back on forth on i. j' heels. DCS 1 verbally prompted:-^ to calm down. On 2/01/07 at 1 0:40 A.M. a review of Client 3's record was conducted. Per a 7/10/03 physician order, Client 3 received • ^___^—m m r— _^__ wee a day for ~~" 'dditionaiiy, the client could receive an additional'" " __ of m _ ~ •. as needed, not to exceed 4 doses in 24 hours. The 8/24/06 Individual Service Plan (ISP) identified goals for Client 3 to decrease tantrum build up behaviors and tantrum behaviors. Tantrum build up behaviors were identified as hand flapping, body rocking, hand wringing and non responsiveness to requests. If the client did ID PREFIX TAG W252 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETION D*T6 FORM CMS-2567(02-99) Previous Versions Obsolete 7GRN11 " con"r"jal'Qn sheet Page 7 erf 11 u j / 0 a / iL a A x ( b o y a bHI, inc.009/012 DEPARTMENT OF HEALTH AND HU.uiAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Printed: 02/09/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CL1A (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BU|LD|NG COMPLETED 05G142 8'W|NG-02/0:J/200T NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA HOUSE 1768 MONTE MAR ROAD VISTA, CA 92084 (X4) 10 PREFIX TAG W252 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG Continued From page 7 W 252 not display build up behavior r ^would receive a piece of candy. If behaviors occurred, staff were to prompt the client to calm down and remove from the group to a quiet area as needed. Per the plan, if the client did not calm down after 10 minutes, V- iaitrvag tn hp niupn Data was documented daily on number of occurrences. if candy was earned and !!^~~ ""Vas given. Tantrum behaviors were identified as 2 or more of the following behaviors: hitting, scratching others, screaming, pounding, stomping, head banging or biting/scratching self. If the client did not display build up behaviors, **~ vould receive a piece of candy. If behaviors occurred, staff were to prompt the client to. calm down and remove from the group to a quiet area as needed. Per the plan, if_the client didjiot calm down after 10 minutes, ^_V_. '1 " J"^was to be given. Data was documented daily on number of occurrences, if candy was earned and if was given. Additionally, a narrative documentation of the Incident was to be completed. A review of the data sheets for the tantrum build up and tantrum behaviors from May 2006 through January 2007 was conducted. Tantrum build up data was not consistently documented. There were multiple instances where documentation related to candy was missing. Additionally, there were was no documentation at all for 5/1 1/06, 5/12/06 and 8/25/06. Tantrum data sheets for May 2006 documented 2 epjsodes that required the administration of \ Although there was a requirement to complete a narrative of each episode, only one was done. Additionally, there was no documentation at all for 5/1 1/06 and 5/12/06. June data sheets documented 4 episodes that PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETIONriATCl/A t C FORM CMS-2567(02-99) Previous,Vsrsjons; Obsolete 7GRN11 Jf tontlpuailon ifteai Paga 8 of 11_ I c n i , nit. DEPARTMENT OF HEALTH AND Hu.MN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Printed: 02/09/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPUER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 05G142 (X2) MULTIPLE CONSTRUCTION <X3) DATE SURVEY A. BUILDING COMPLETED B. WING 02/OJJ/2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE VISTA HOUSE 1768 MONTE MAR ROAD VISTA, CA 92084 (X4JID PREFIX TAG W371 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 10 On 1/30/07 at 4:00 P.M. Client 3 returned to the facility from day program. The client was alert and able to communicate verbally. The client was independently ambulatory. At 4:35 P.M. a medication administration observation was conducted. Client 3 independently got a glass of water from the kitchen sink. The client then ambulated to the family room and sat in a chair beside the desk. Direct Care Staff (DCS) 1 placed " ' —- — paper cup and gave the cup to tne client. The medication was not identified nor were the indications or side effects discussed with the client. The client tipped the medication in her mouth and swallowed with a sip of water. The client then independently threw away the cup. On 2/01/07 at 10:40 A.M. a review of Client 3's record was initiated. The 8/24/06 annual Individual Service Plan (ISP) did not address the client's abilities related to medication administration. The ISP did not include a goal to provide training to increase Client 3's participation in "~2 dedication regimen. An interview was conducted with Jb"1 MB ^**^" ' ^fe nn 2/01/07 at 2:25 P.M. Thsta^pac nowledged that Client 3's ISP did not induce a medication administration goal. The v^. V stated that a medication related goal "had been missed" and that Client 3 would benefit from the additional training. ID PREFIX TAG W371 PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE APPROPRIATEDEFICIENCY) . CU*~V &?> w*-« ^CA~-.-H.IA \^Jf a^. ^0 N^tt.4A~A ^W-K- <<lUs.x^».S ^-Scxx^^J. Cl.'e-4-J vdiU W. w-e>rW<* tr~- <•- <\*f*^ ^ iO w/ Mr?~o v~-<U- -"TW. 1 0 A-0<M^v. C^— -^ ^fXX^A"-"-! -"•" ;5 ^^-^o-v^I^U. H-s\y<. **• \ \ v ** *w c*4*.^V»**'< «-f I oO"' \ o\\<^<> ^- <u4^^^ r~\t & *»*— P<S) COMPLETION DATE '[-»] ^ FORM CMS-2567(02-99) Pravious Versions Obsolete 7GRN11 If contintaUon sheet Page 11 pfj 1_ DEPARTMENT OF HEALTH AND HU i SERVICES CENTERS FOR MEDICARE & MEDIC/-,.^ SERVICES PRINT tU: 12/24/200/ FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTIOI^C JJ \J JJr. .(X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ^ fTM^^A //£-£ COMPLETED A. BUILDING W > 05G952 BWING 12/1:J/2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA COSTA HOUSE 6433 FLAMENCO STREET CARLSBAD, CA 92008 (X4) ID PREFIX TAG WOOD C$r W124 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) INITIAL COMMENTS The following reflects the findings of the California Department Public Health during a FUNDAMENTAL Survey. Representing the Department: Sharon Allen, HFEN, and Christine Reed, HFEN. The census during the survey was 6 clients. The survey sample was 3 clients. 483.420(a)(2) PROTECTION OF CLIENTS RIGHTS The facility must ensure the rights of all clients. Therefore the facilty must inform each client, parent (if the client is a minor), or legal guardian, of the client's medical condition, developmental and behavioral status, attendant risks of treatment, and of the right to refuse treatment. This STANDARD is not met as evidenced by: Based on staff interview and clinical record review, the facility failed to obtain informal ID PREFIX TAG WOOD W124 \JV consent for the use of a for 1 of 3 sampled clients (Client 1). Findings: Client 1 was admitted to the facilih/ nn 9/7/82. withd • includerU faTi? >er me Admission and Discharge Record. On 12/14/07 at 10:00 A.M., Client 1's clinical record was reviewed. The physicians order dated ^2/6/Q7 inr.lnHoH an nrH(=r for ^ \2 mgr(milligrams) to be PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ^___ -—-I [rnT¥5JlMifn\ HUJr ~ 111 II fnl JAN 1 0 2°08 H--'l 1 1 __-_-J 1 1 7^MAw"ctR^ 1 1 ^SANDlHOISTRIClOm^ \ V\ \ *\ f AVS, ^ ^J'WT f\/jt ^ O tf- &~ I v\ \ \ \^> \^r\s \ 1*^ V'TV * K-^"^ t^-v-- •*-' * ^ jvv^AdAW WU' ^ $\&£b0)tyo{'e' > [s£(£xSW\faA<f\:%S . L3» 1 1 / ^V^5> b^^vi Co*/\ \&-&^c^ ' * — r_ LJL ' ' r 0J^o OV\^ 0te\At\*\t^ (M £>**& Ojfe C\A/W&(\T • (X5) COMPLETION DATE . , I 13 0^y '/ LABORATORY DIRCTOR'S OR-PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution njfey be excused from correcting providing it is deterfnine'd that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01111 Facility ID: CA090000123 If continuation sheet Page 1 of 6 DEPARTMENT OF HEALTH AND HU I SERVICES CENTERS FOR MEDICARE & MEDIC^.-y SERVICES PRINTED: 12/24/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 05G952 B'WING 12/1:J/2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA COSTA HOUSE 6433 FLAMENCO STREET CARLSBAD, CA 92008 (X4) ID PREFIX TAG W124 W322 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 given every day. The required form, "Consent For Use of\ F, was not signed by Client 1's responsible party. Durinn an interview on 12/14/07 at 10-1S A.M., the acknowledged that the consent form for Client 1 had not been signed. This was a repeat deficiency. 483.460(a)(3) PHYSICIAN SERVICES The facility must provide or obtain preventive and general medical care. This STANDARD is not met as evidenced by: Based on interview and record review, the facility failed to ensure the annual EKG (electrocardiogram) examinations were done as ordered, for 3 of 3 sampled clients (Client 1, Client 2, and Client 3). Findings: 1 . Client 1 was admitted to the facility on 9/7/82, with diaeinnsis thqt included ~ according tu me ^nci u Identification aTTd Emergency Information form. On 12/14/07 at 8:30 A.M., Client 1's clinical record was reviewed. The Physician's Order sheet dated 7/19/07 included an order for an EKG to be done annually. The last FKG report indicated that Client 1 had^ ast EKG examination on 10/13/06. ID PREFIX TAG W124 W322 V w\s PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) fW W$4vrt<\ W\£ be^vi / \ I P i^>oriewJM>*-(A Qjf\c\ £\ {j/vS^uTe. -\v\<x/v CMMntteu pL^/l> /* ._ />jt)M(^ L>JLx/J \A \ A J-i " /ft. ""H-^c'lu \\MJM\&T- 9K) fS^pcM^to W-'izX' £2o£U/ / • "T^Cl ^&ty(s\Cc& Y£&T£> &fz^ f\f9yvitslf \ffk fo)t\A A/}/" it Wi y%c4 \ C)t>\tiv/\<f^ (X5) COMPLETION DATE 0 1^ \0e& I«AJ I -^ FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01111 Facility ID: CA090000123 If continuation sheet Page 2 of 6 DEPARTMENT OF HEALTH AND HU i SERVICES CENTERS FOR MEDICARE & MEDIC... J SERVICES FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER:A. BUILDING 05G952 B'WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA COSTA HOUSE 6433 FLAMENCO STREET CARLSBAD, CA 92008 (X4) ID PREFIX TAG W322 W327 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 2. Client 2 was admitted to tl" r~-:lit" "n "10/95, with diagnosis that included/1. , / according to the w,,^m IMCI imitation ana tmergency Information form. On 12/14/07 at 9:00 A.M., Client 2's clinical record was reviewed. The Physician's Order sheet dated 2/17/06, included an order for an EKG to be done annually. The last EKG report indicated that Client 2 had' sst EKG examination on 10/13/06. 3. Client 3 was admitted to the facility op 5/3/85, with diagnosis that included according to the Client laentitication ana tmergency Information form. On 12/14 07 at 9:15 A.M., Client 3's clinical record was reviewed. The Physician's Order sheet dated 2/17/06, included an order for an EKG to be done annually. There was no documentation to show when the last EKG examination was done. On 12/14/07 at 9:30 A.M.. durina interview, the was unable to provide documentation that annual EKG examinations for 2007 were completed for Client 1, Client 2 and Client 3. 483.460(a)(3)(iv) PHYSICIAN SERVICES The facility must provide or obtain annual physical examinations of ee^ client that at a minimum includes '__ ;ontrol, appropriate to the facility's population, and in accordance with the recommendations of the American College of Chest Physicians or the section on diseases of the chest of the American Academy of Pediatrics, or both. ID PREFIX TAG W322 W327 \J (X3) DATE SURVEY COMPLETED 12/13/2007 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Tr\<± , £&\ \NiA.t> Co I \v\ t\ \ 0^ • *"fe^ » * ^^ iM 4 a <WpWt£ +-^ i *A (X5) COMPLETION DATE jj^H FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01111 Facility ID: CA090000123 If continuation sheet Page 3 of 6 DEPARTMENT OF HEALTH AND HU ' SERVICES CENTERS FOR MEDICARE & MEDICA.u SERVICES PRINTED: 12/24/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER LA COSTA HOUSE (X4) ID PREFIX TAG W327 W 383 (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER:A. BUILDING 05G952 BWING STREET ADDRESS, CITY, STATE, ZIP CODE 6433 FLAMENCO STREET CARLSBAD, CA 92008 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 This STANDARD is not met as evidenced by: Based on interview failed to ensure! and record review, the facility i testing was done for 1 registered nurse (RN) in accordance with the facility's policy and procedure on employee testing for' Findings: On 12/13/07 at 2:00 P.M., RN 1's personnel file was reviewed. There was no documentation to show RN 1 received a 5st. According to the facility's policy and procedure titled, "Employment Requirements", dated 2/07, regular, on-call and substitute staff working in the Residential Services Propram are reguired to receive a physical and af st annually. During an interview on 12/13/07 at 2:30 p.m., the human resource manager acknowledged there Vioo -(- -• ientation to indicate RN 1 received ^ > required. 4fao.4t>U(l)(2) DRUG STORAGE AND RECORDKEEPING Only authorized persons may have access to the keys to the drug storage area. This STANDARD is not met as evidenced by: Based on observation and interview, the facility failed to ensure only authorized personnel had access to the keys area. to the medication storage ID PREFIX TAG W327 \ W A A A383 V (X3) DATE SURVEY COMPLETED 12/13/2007 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) TU ftUlw6b**«V / f \\ 1A f _L ^=/F\ T ~rV\£ Vlff (A ~W t>lw C/\s » ' I \ £w)cr>a( »la Ul^- \Mi^kd\l teOMeA \L^<^S- \)\(Z.CA&( (A NS^A^WV SeXVl££5 Y<b£ V0^fo>\ V> I* Z? J~ '\A -Xl/\ 4 X?V\A\Cxf) £>U,» \*\A ~rvV£Tr C^TVV (Xfe Cl/LW&v\\ 0f\ &\ \fc/Jt\JL\f&M6v()££ | , V/Y ,\ j^j^r&Jrki^C ^^^* * C^^ * *^^ ^^. \)/&&f\ fe- V«\£>TYiAcA'tf^f 1 / \i ryCo^ef meAW?c\ 04 £< ^VUtvT/lio^x \\ssu$ . ^) ^J } ^ ? W4»D/7(S<o Kl~ 'Tt\ ' 'C'=7|r^'»>v>t C £> Asvf4' Od(w &t\&\JiX(n6\ \C4\ ^ \>S . \/)/icx^p<^5 -)/XV<2^|^v » \^^ . 10 r \ h/ -K21V CPMpl\4. ^ (X5) COMPLETION DATE •A 1 \ /i^71 l^-jtnj - >t«A^_J v>6^ FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01111 Facility ID: CA090000123 If continuation sheet Page 4 of 6 DEPARTMENT OF HEALTH AND HU \ SERVICES CENTERS FOR MEDICARE & MEDIC/-..^ SERVICES PRINTED: 12/24/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER LA COSTA HOUSE (X4) ID PREFIX TAG W383 W426 (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER:A. BUILDING 05G952 BWING STREET ADDRESS, CITY, STATE, ZIP CODE 6433 FLAMENCO STREET CARLSBAD, CA 92008 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 Findings: On 12/12/07 at 8:30 A.M., during the medication pass observation, the house manager (HM) left the medication storage keys in an unlocked drawer, that was accessible to anyone. On 12/13/07 at 8:00 A.M., while administering the morning medications, the HM left the keys in the unlocked top drawer. The keys were accessible to anyone. During an interview with the HM on 12/1 3/07 at 8:30 A.M., she acknowledged the medication storage keys should not have been left unattended. 483.470(d)(3) CLIENT BATHROOMS The facility must, in areas of the facility where clients who have not been trained to regulate water temperature are exposed to hot water, ensure that the temperature of the water does not exceed 110 degrees Fahrenheit. This STANDARD is not met as evidenced by: Based on observation and interview, the facility failed to assure that clients did not have access to to the water temperature control dial of the water heater. Findings: During the environmental observation on 12/13/07 at 10:15 A.M., the water heater temperature control dial was noted to be accessible to the clients. There was no restrictive device or cover to safeguard the water temperature regulator dial. ID PREFIX TAG W383 W426 \V (X3) DATE SURVEY COMPLETED 12/13/2007 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) I M<! Q\A\ \\(te \>&&Y( Ci VA/ , v JfrOw\\i2''<(\0jf\o£s £U£&f r * X<££> Qf\A £> i \>\e, ~\frf fffrfc . /I5£7f' •?urw£ ~-~j -\i\&J\ ~&r\\J \ir<£) fl w\&r\ r* \f> £^trC- (X5) COMPLETION DATE I I3J0B FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01111 Facility ID: CA090000123 If continuation sheet Page 5 of 6 DEPARTMENT OF HEALTH AND Hi I SERVICES CENTERS FOR MEDICARE & MEDIC,..j SERVICES Printed: 01/23/2008 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER LA COSTA HOUSE (X4) ID PREFIX TAG W426 W438 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 05G952 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 12/13/2007 STREET ADDRESS, CITY, STATE, ZIP CODE 6433 FLAMENCO STREET CARLSBAD, CA 92008 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 5 necessary safeguard device. 483.470(h)(1) EMERGENCY PLAN AND PROCEDURES The facility must develop and implement detailed written plans and procedures to meet all potential emergencies and disasters such as fire, severe weather, and missing clients. This Standard is not met as evidenced by: Based on observation and interview, the facility failed to have a detailed plan to specify the amount of water necessary for each client in the event of a disaster or emergency. Findings: On 12/13/07 at 8:15 A.M., inspection of the facility's emergency food supply was conducted. The emergency supply of water did not have a specified quantity designated for each individuals' provision. On 12/13/07 at 8:45 A.M., the facility's policy and procedure, titled, "Emergency Supplies" was reviewed. The policy did not include the quantity of water to be stored, in order to provide for the 6 clients residing at the facility in the event of an emergency. ID PREFIX TAG W426 W438 PROVIDER'S PLAN OF CORRECTION {EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) •ftcl Te/0u WUwfi , CTYtcrW tfc fuWrfewkflj ****** * fctfi**J < PAG- tAMZ/v^WCL^ ( (&t\ • lftC\AAAt *^r $&Hflli$ bf -ft W Ao'&i W>!$ *i c* • pQ*\ ^{/Tfityt'VGOj, yof t/£& G4/0«T"C % J? ^frTiJj- A O^^» -C/|vJ O j ^ ^( ^|T ' Hvi dtf ' w\\ f^okjfJh^ . n\ rfe ^t\^f(\^flnyt fo/ ynffYJiif , J , ' V \J (J , « . ftiCfUvw- V (^^ -ttlcf ^ t \JU h ' W^rCr ie & • . : :••-•». (?M (, (&w£i)' I t±*jQit\ti Tnrirtft ^ ? Av\Atl tH?U2(J^1? (X5) COMPLETION DATE !-lwrf^ .... I 'll* JL &/>K^-/I 1 FORM CMS-2567(02-99) Previous Versions Obsolete UO1I11 If continuation sheet Page 6 of 6 Department of Health and Human Servic' Centers for Medicare & Medicaid Service t-orm approved OMB NO. 0938-0390 Post-Certification Revisit Report Public reporting for this collection of information is estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing the burden, to CMS, Office of Financial Management, P.O. Box 26684, Baltimore, MD 21207; and to the Office of Management and Budget, Paperwork Reduction Project (0938-0390), Washington, D.C. 20503. (Y1) Provider/ Supplier /CLIA/ Identification Number 05G952 (Y2) Multiple Construction A. Building B. Wing Name of Facility LA COSTA HOUSE (Y3) Date of Revisit 1/13/2008 Street Address, City, State, Zip Code 6433 FLAMENCO STREET CARLSBAD, CA 92008 This report is completed by a qualified State surveyor for the Medicare, Medicaid and/or Clinical Laboratory Improvement Amendments program, to show those deficiencies previously reported on the CMS-2567, Statement of Deficiencies and Plan of Correction that have been corrected and the date such corrective action was accomplished. Each deficiency should be fully identified using either the regulation or LSC provision number and the identification prefix code previously shown on the CMS-2567 (prefix codes shown to the left of each requirement on the survey report form). (Y4) item (Y5) Date (Y4) Item (Y5) Date (Y4) Item (Y5) Date ID Prefix W0124 Correction Completed 01/13/2008 Reg. # 483.420(aU2) LSC ID Prefix W0383 Correction Completed 01/13/2008 Reg.# 483.460(IM2) LSC ID Prefix Correction Completed Reg.# LSC ID Prefix Correction Completed Reg.# LSC ID Prefix Correction Completed Reg. # LSC Reviewed By State Agency CMSRO Reviewed By Ttf Reviewed By Followup to Survey Completed on: 12/13/2007 Correction Completed ID Prefix W0322 01/13/2008 Re9'# 483.460(a)(3) LSC Correction Completed ID Prefix W0426 01/13/2008 Re9-# 483.470(dM3) LSC Correction Completed ID Prefix Reg. # LSC Correction Completed ID Prefix Reg. # LSC Correction Completed ID Prefix Reg. # LSC ID Prefix W0327 Correction Completed 01/13/2008 Re9- * 483.460(a)(3)(iv) LSC ID Prefix W0438 Correction Completed 01/13/2008 Reg. # 483.470(h)m LSC ID Prefix Correction Completed Reg.# LSC ID Prefix Correction Completed Reg.# LSC ID Prefix Correction Completed Reg. # LSC Date: Signature of Surveyor: /~23'Af ^ftfl/&ft/3/vt^y klf£S Date: Signature of Surveyor: Check for any Uncorrected Defici Uncorrected Deficiencies (CMS sncies. Was a Summary of -2567) Sent to the Facility? Datet «3-tf Date: YES NO Form CMS - 2567B (9-92)Page 1 of 1 Event ID: U01I12 California Department of Public Healt i c.u. i FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER LA COSTA HOUSE (X4) ID PREFIX TAG BOOO (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER:A. BUILDING B. WINGCA090000123 STREET ADDRESS, CITY, STATE, ZIP CODE 6433 FLAMENCO STREET CARLSBAD, CA 92008 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Initial Comments The following reflects the findings of the California Department of Public Health during an entity reported incident investigation: Complaint Number: CA00133790 Category: Quality of Care/Treatment Representing the Department: Christine Reed, HFEN The inspection did not represent the findings of a full inspection of the facility. The Department was unable to substantiate a violation of the regulations. ID PREFIX TAG BOOO (X3) DATE SURVEY COMPLETED 12/13/2007 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ~:=^\W7F r — — . r-3 n n nn E L fe ii \v/UJ rn)J LJ! DEC I i-ICEfJSIi'JR M — '- 2 4 2007 n'rcQ-n^r ^'0:;";u'V.rc (X5) COMPLETE DATE F frT\ J— - 1 1 1 1 j Wli !— ' I i. f. ; LABORATOR^DiREerOflfe OR^PROVKJER/SUPPLIER REPRESENTATIVE'S StGNATURr (XB)DATE STATE FORM If continuation srfeet 1 of 1 California Department of Public Health • PRINTED: 09/19/2007 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETEDA. BUILDING B. WINGCA090000123 08/16/2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA COSTA HOUSE 6433 FLAMENCO STREETCARLSBAD, CA 92008 (X4) ID PREFIX TAG BOOO SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Initial Comments The following reflects the findings of the California Department of Public Health during the investigation of one (1) entity reported incident. Entity reported incident: CA00122918 Representing the Department: Aty Knooren, HFEN. The inspection was limited to the entity reported incident investigated and does not represent the findings of a full inspection of the facility. No deficiencies were issued for entity reported incident CA00122-918. ID PREFIX TAG BOOO * PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) -. ^\Ai (X5) COMPLETE DATE LABORATORY PIRECTQB'S OR PROVIDER/SJ^PLIER REPRESENTATIVE'S SIGNAJURE ». ' e~\ TlAi STATE FORM/ l/fO^^S?', (X6) DATE UEKK11 If continuation sheet 1 of 1 PRINTED: 08/10/2007 FORM APPROVED California Department of Pub ic Healu, STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING B. WINGCA090000123 08/1 (J/2UU / NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA COSTA HOUSE 6433 FLAMENCO STREET CARLSBAD, CA 92008 (X4) ID PREFIX TAG BOOO SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Initial Comments 'jT)/(cjr The following represents the findings of the Department of Public Health during an entity reported incident investigation. Complaint Number: CA00121027 Category: Physical Environment The inspection did not represent the findings of a full inspection of the facility. Representing the Department of Public Health: Christine Reed, HFEN ID PREFIX TAG BOOO PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) I (X5) COMPLETE DATE LABORATOR IOV1DER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE ) DATE OLTU11 If continuation sheet 1 of 1 I MtN I Ul- HtAL I H AND HUMAN SERVICES CENTERS FOR MEDICARE & MED[ SERVICES !_/. W t / £.\Jt £.\J\J f FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER LA COSTA HOUSE (X4) ID PREFIX TAG WOOD W 124 (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER:A. BUILDING 05G952 BWING (X3) DATE SURVEY COMPLETED 01/19/2007 STREET ADDRESS, CITY, STATE, ZIP CODE 6433 FLAMENCO STREET CARLSBAD, CA- 92008 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) INITIAL COMMENTS The following reflects the findings of the Department of Health Services during a FUNDAMENTAL survey. Representing the Department: Aty Knooren, HFEN. The census at the time of the survey was 6 clients. The sample size was 3 clients. 48.3.420(a)(2) PROTECTION OF CLIENTS RIGHTS The facility must ensure the rights of all clients. Therefore the facility must inform each client, parent (if the client is a minor), or legal guardian, of the client's medical condition, developmental and behavioral status, attendant risks of treatment, and of the right to refuse treatment. This STANDARD is not met as evidenced by: Based on interview and record review the facility faiip>H tn nhtain informed consents for the use of Dedications for 2 of 3 sampled clients (1, 3). Findings: 1. According to the client's race sneet, uient i was admitted to the facility on 11/9/R7 with Hiann^cQc that included! Record review on 1/18/07 indicated that according to the physician order form dated 11/06, CHentl had ID PREFIX TAG wooo W124 an order for, PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ' Consents have been resent to family members and will follow up with phone call if necessary. ^ responsible for ensuring consents are signed in a manner. r\\JniUli timely FEB 1 6 2007 LICENSING AND CERTIFICATI SAN DIEGO DISTRICT OFFICE SC 2 tablets' every night fou_ _._ _.. fcA, (XS) COMPLETION DATE /' 2M'Q/07 "^\\ \ > P"v \n M ON UTH J R PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE (X6) DATE un Any deficiency-statement ending with an astero^f) denotes a deftciencywhlch the institutionmay be excused/rim correcting providing it is determineofthat other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, theUmdings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions ObsoJete Event ID: 276011 Facility ID: CA090000123 If continuation sheet Page 1 of 3 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDli SERVICES FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 05G952 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETEDA. BUILDING B. WING 01/11 )/2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA COSTA HOUSE 6433 FLAMENCO STREET CARLSBAD, CA 92008 (X4) ID PREFIX TAG W124 W261 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 There was also a second order for^__J T~ 1 tablet as needed, at niaht if not asleep oy TlfOO P.M. The consent fo > /as dated 8/5/Ofi Tho "consent for use^i . . forms dated 10/10/06 indicated that the consents were valid for a period of one year. Tl--~ fas interviewed on 1/18/07 at 3:00 P.M. bne acKnowledged that the consent was not signed on an annual basis. 2. According to the client's face sheet, Client 3 was admitted to the facilitv on 9/1/82 with diagnoses that included^ Record review on 1/18/07 indicated that according to the physician order form Hatpd 1 1/06, Client 3 had an order foiv ••->\tery mnrninq anrli _ _ very evenina fn- f The "consent for use nf£ \ form dated 7/21/05 indicated that the consent was valid for a period of one year. Thf4 ^^ ' was interviewed on 1/18/u/ ai o.uu r .,*. She acknowledged that the consent was not signed on an annual basis. 483.440(f)(3) PROGRAM MONITORING & CHANGE The facility must designate and use a specially constituted committee or committees consisting of members of facil ty staff, parents, legal guardians, clients (as appropriate), qualified persons who have either experience or training in contemporary practices to change inappropriate ID PREFIX TAG W 124 \ '-. W261 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) A community representative has been identified for the HR Committee. Director of Adult Services responsible for compliance (X5) COMPLETION DATE 2/19/01 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 276011 Facility ID: CA090000123 If continuation sheet Page 2 of 3 DEPARTMENT OF HEALTH AND HU SERVICES CENTERS FOR MEDICARE & MEDIC^.u SERVICES Printed: 02/21/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BU|LD|NG COMPLETED 05G952 BWING 01 /iy /2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA COSTA HOUSE 6433 FLAMENCO STREET CARLSBAD, CA 92008 (X4) ID PREFIX TAG W261 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 This Standard is not met as evidenced by: Based on interview and record review the facility failed to have a community representative participate in the human rights committee. The community representative is the person on the committee without ownership or controlling interest in the facility. Findings: Record review of the quarterly human rights (HR) committee forms on 1/18/07 at 3:00 P.M. indicated that there were no signatures of the facility's community representative. Thef ,. - 'asiriFe'rv'leWeaon i/io/O/ at4:OUH.M. TFiel ^acknowledged that they did not have a community representative on the the HR committee. ID PREFIX TAG W261 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ! (X5) COMPLETION FQ_RM.CM&L2567(02-99) Previous Versions Obsolete 276Q11 Ifcontinuation sheetPage 3of 3 Department of Health and Human Services Centers For Medicare & Medicaid Services Form Approved OMB NO. 0938-0390 Post-Certification Revisit Report Public reporting for this collection of information is estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing th« burden, to CMS, Office of Financial Management, P.O. Box 26684, Baltimore, MD 21207; and to the Office of Management and Budget, Paperwork Reduction Project (0938-0390), Washington, D.C. 20503. (Yl) Provider/ Supplier /CLIA/ Identification Number 05G952 (Y2) Multiple Construction A. Building B. Wing Name of Facility LA COSTA HOUSE (Y3) Date of Revisit 01/25/2007 Street Address, City, State, Zip Code 6433 FLAMENCO STREET CARLSBAD, CA 92008 This report is completed by a qualified State surveyor for the Medicare, Medicaid and/or Clinical Laboratory Improvement Amendments program, to show those deficiencies previously reported on the CMS-2567, Statement of Deficiencies and Plan of Correction that have been corrected and the date such corrective action was accomplished. Each deficiency should be fully identified using either the regulation or LSC provision number and the identification prefix code previously shown on the CMS-2567 (prefix codes shown to the left of each requirement on the survey report form). (Y4) hem (Y5) Date (Y4) Item (YS) Date (Y4) Item (Y5)Date ID Prefix WO 124 •- •• • Correction Completed 02/19/2007 ReS'# 483.420(a)(2) LSC ID Prefix Correction Completed Reg.# LSC ID Prefix Correction Completed Reg.# LSC ID Prefix Correction Completed Reg. # LSC ILTPrefix Correction Completed Reg.# LSC Reviewed By State Agency Reviewed By CMSRO Reviewed By Reviewed By Followup to Survey Completed on: 01/19/2007 Correction Completed ID Prefix W0261 02/19/2007 ReS-# 483.440(0(3) LSC Correction Completed ID Prefix Reg.# LSC Correction Completed ID Prefix Reg.# LSC Correction Completed ID Prefix Reg.# LSC Correction Completed ID Prefix Reg.# LSC Date: Signature of Surveyor: y^J^e^^^^^-^0Date: Signature of Surveyor: ID Prefix Correction Completed Reg.# LSC ID Prefix Correction Completed Reg.# LSC ID Prefix Correction Completed Reg. # LSC ID Prefix Correction Completed Reg.# LSC ID Prefix Correction Completed Reg.# LSC Date: --Vk^-7 Check for any Uncorrected Deficiencies. Was a Summary of Uncorrected Deficiencies (CMS-2567) Sent to the Facility? y£§ NQ Form CMS - 2567B (9-92)276012 or neann ana numan service/ Centers for Medicare & Medicaid Servk Form Approved OMB NO. 0938-0390 Post-Certification Revisit Report Public reporting for this collection of information is estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing the burden, to CMS, Office of Financial Management, P.O Box 26684, Baltimore, MD 21207; and to the Office of Management and Budget, Paperwork Reduction Project (0938-0390), Washington, D.C 20503. (Y1) Provider/ Supplier/ CLIA / Identification Number 05G376 Name of Facility ORIENTE HOUSE (Y2) Multiple Construction A. Building B. Wing (Y3) Date of Revisit 10/1/2008 Street Address, City, State, Zip Code 3081 ORIENTE DRIVE VISTA, CA 92083 This report is completed by a qualified State surveyor for the Medicare, Medicaid and/or Clinical Laboratory Improvement Amendments program, to show those deficiencies previously reported on the CMS-2567, Statement of Deficiencies and Plan of Correction that have been corrected and the date such corrective action was accomplished. Each deficiency should be fully identified using either the regulation or LSC provision number and the identification prefix code previously shown on the CMS-2567 (prefix codes shown to the left of each requirement on the survey report form). (Y4) item ID Prefix Reg.# LSC ID Prefix Reg.# LSC ID Prefix Reg. # LSC ID Prefix Reg.# LSC ID Prefix Reg. # LSC (Y5) Date (Y4) Item Correction Completed W0331 10/01/2008 483.460(c) Correction Completed W0383 10/01/2008 483.460(0(2) Correction Completed Correction Completed Correction Completed Reviewed By (ZfQ \ Reviewed By State Agency '\jtfC* /ck A ,* fa^ Reviewed CMS RO By I Reviewed By Followup to Survey Completed on: 9/25/2008 ID Prefix Reg. # LSC ID Prefix Reg.# LSC ID Prefix Reg.# LSC ID Prefix Reg. # LSC ID Prefix Reg.# LSC (Y5) Date (Y4) Item (Y5) Date Correction Completed W0342 10/01/2008 483.460(c)(5)(iii) Correction Completed ID Prefix W0377 10/01/2008 Re9 * 483.460(0(1) LSC Correction i Correction Completed Completed W0455 10/01/2008 ID Prefix W0483 10/01/2008 483.470(11(1) Correction Completed Correction Completed Correction Completed Date: Date: Reg. # 483.480(d)(2) LSC Correction Completed ID Prefix Reg. # LSC Correction Completed ID Prefix Reg.# LSC Correction Completed ID Prefix Reg. # LSC i ISignature of Surveyor: Date: | Signature of Surveyor: L/ Date:i Check for any Uncorrected Deficiencies. Was a Summary of Uncorrected Deficiencies (CMS-2567) Sent to the Facility? YES NQ Form CMS - 2567B (9-92)Page 1 of 1 Event ID: G2PE12 DEPARTMENT OF HEALTH AND HUM . SERVICES CENTERS FOR MEDICARE & MED, ^ SERVICES STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2 AND PLAN OF CORRECTION IDENTIFICATION NUMBER:A. E 05G376 B V NAME OF PROVIDER OR SUPPLIER ORIENTS HOUSE (X4) ID PREFIX TAG W331 PRINTED: 10/03/2008 FORM APPROVED ' OMB NO. 0938-0391 MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETEDUILDING VING 09/2!3/2008 STREET ADDRESS, CITY, STATE, ZIP CODE 3081 ORIENTE DRIVE VISTA, CA 92083 SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX i (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Continued From page 2 W 331 "Allergies-Bees" was dated 9/20/01 and had a review date of 7/8/08. The care plan did not address allergies to bee stings nor did the care plan indicate intervention for the use of the i epi-pen. W342 An interview was conducted with Licensed staff on 9/24/08 at 2:30 P.M.. icknowledged the care plan titled "Allergies-dees", did not specically address Bee stings nor the use and purpose of the epi-pen. I.e. Client 1's record review was conducted on 9/24/08 at 9:30 A.M.. indicated the nursing ! monthly summary for July and August 2008 were ' not in the record. • An interview was conducted with *^e Licensed staff on 9/24/01 at 2:30 P.M.. _ stated the monthly summary for July and August 2008 were '. not in the clinical record because they were not i done. 483.460(c)(5)(iii) NURSING SERVICES j W 342 Nursing services must include implementing with other members of the interdisciplinary team, I appropriate protect ve and preventive health measures that include, but are not limited to i training direct care staff in detecting signs and ' symptoms of illness or dysfunction, first aid for accidents or illness, and basic skills required to j meet the health needs of the clients. | j I This STANDARD is not met as evidenced by: Based on observation, interviews and record review the facility failed to provide training to ! direct care staff related to 1 of 3 sample clients j (1) who required to have an epi-pen (autoinjector i | The facility shall provide appropriate I protective and preventive health measures. The Nurse Case Manager j has written a care plan and inserviced ! the staff regarding the use of the epi- pen and the need for Client 1 to have it on their person wher leaves the facility. The Director of Residential Services shall ensure continued compliance by random quality assurance audits and direct i observation.i (X5) COMPLETION DATE 10/1/08 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G2PE11 Facility ID: CA090000771 If continuation sheet Page 3 of 9 DEPARTMENT OF HEALTH AND HUM SERVICES CENTERS FOR MEDICARE & MEDI ,_ oERVICES PKlNltu: FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES , AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER ORIENTE HOUSE (X4) ID PREFIX (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 05G376 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL i TAG REGULATORY OR LSC IDENTIFYING INFORMATION) [ W 342 Continued From page 3 of epinephrine)on'"> person at all times for an (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING ID STREET ADDRESS, CITY, STATE, ZIP CODE 3081 ORIENTE DRIVE VISTA, CA 92083 (X3) DATE SURVEY COMPLETED 09/25/2008 PROVIDER'S PLAN OF CORRECTION (X5) PREFIX I (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG : CROSS-REFERENCED TO THE APPROPRIATE ! DATE : DEFICIENCY) W 342 : allergic reaction to oee stings.As a result, direct i care staff were unaware of the epi-pen and it's use. Findings: Per the Client Identification and Emergency I jI Information sheet. Client 1 was admitted to the i facility with diagnosis that included, Per the had severe asthma same document the client ( swelling of the airway in the I lungs making it difficult to breath). It was noted on I the document that Client 1 had an epi-pen available. An observation and interview was conducted on 9/22/08 at 7:30 P.M. of the medication storage area. A black fanny pack was observed that contained an epi-pen. Direct care staff 3, stated that the fanny pack Client 1. and epi-pen belonged to Client 1's record review was conducted on : 9/24/08 at 9:30 A.M. There was a physician's •i order for Client 1 for the "epi-pen 0.3 mg ; i (micrograms) auto-inj(auto injector) to use for emergency allergy reactions" An interview was conducted with Licensed staff on 9/24/08 at 2:30 P.M.. _ stated that the epi-pen was supposed to be with Clientl at all times. Licensed staff stated that the epi-pen was kept on the Client ir "~ ackpack. An interview and observation was conducted with the van driver on 9/24/08 at 2:45 P.M. Client 1 j i j was observed sitting in the back set. The van driver stated that Client 1 did not carry a I FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G2PE11 Facility ID: CA090000771 If continuation sheet Page 4 of 9 DEPARTMENT OF HEALTH CENTERS FOR MEDICARE STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER ORIENTE HOUSE (X4) ID PREFIX TAG WOOO W331 AND HUM' SERVICES &MEDI .^SERVICES I (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: A. BUILDING 05G376 B. WING STREET ADDRESS, CITY 3081 ORIENTE STATE, ZIP CODE PRINTED: 10/03/2008 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED 09/25/2008 DRIVE VISTA, CA 92083 SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) <X5) COMPLETION DATE INITIAL COMMENTS WOOO j The followina reflects the findings of the California Department of Public Health during a : FUNDAMENTAL survey. ji Representing the California Department of Public : Health: Noreen Valentine, HFEN and Christine Reed, Then census of the facility during the survey was 6 clients. The sample size was 3 clients. 483.460(c) NURSING SERVICES The facility must provide clients with nursing services in accordance with their needs. This STANDARD is not met as evidenced by: Based review on observation , interviews, and record the facility failed to ensure that 1of 3 sample clients (1) health needs were met related to allergies to bee stings. The staff were unaware of Client 1's allergies to bee stings and the need for an epi-pen (autoinjector of epinephrine). A care plan was not developed related to specific interventions for bee stings and the use of an epi-pen. Additionally, 2 consecutive nursing monthly summary were not in the clinical records. Findings: ™ '-•»», ~"\Ju. \ /ni IF P l£ IMIE ly? E U E — P OCT 1 6 2008 [L LICENSING AND CERTIFICATION SAN DIEGO DISTRICT OFFICE W331 The facility nursing shall provide clients with services in accordance with their needs. The Nurse Case Manager has written a care plan with specific interventions for bee stings for client 1 and the need/use of the epi-oen. The client has a fanny pack that* carries to/from day program and on outings that holds the epi-pen. All staff have been trained/retrained on this 1 procedure as ! Residential Per the Client Identification and Emergency i Nurse Case well. The Director of Services has counseled the Manager for not having Information sheet. Client 1 was admitted to the , completed two consecutive nursing facility with diagnosis that included,! ~ H monthlies. i Per the had severe asthma The Director of Residential same document the ciieni ; Services shall ( swelling of the airway in the compliance ensure continued by random quality lungs making it difficult to breath). It was noted on , assurance audits andsdirect LABORTPSfiB^IReCKCMR'fc &Fpf R«VK V JvJf ' )tfVtLtf>t>UER REPRESENTATIVE'S SIC MIIL.^ pfji NATUREof/1 DDsenyatioJBilwlfoiur \ L „.\dlMm V J 10/1/08 n A A (XBJDATEiCtte.. Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G2PE11 Facility ID: CA090000771 If continuation sheet Page 1 of 9 DEPARTMENT OF HEALTH AND HUM SERVICES CENTERS FOR MEDICARE & MEDI. ,- SERVICES PRINTED: 10/03/2008 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 05G376 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 09/25/2008 NAME OF PROVIDER OR SUPPLIER ORIENTE HOUSE STREET ADDRESS, CITY, STATE, ZIP CODE 3081 ORIENTE DRIVE VISTA, CA 92083 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES ! ID (EACH DEFICIENCY MUST BE PRECEDED BY FULL i PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) I TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE W331 Continued From page 1 the document that Client 1 had an epi-pen available. 1.a. An observation and interview was conducted on 9/22/08 at 7:30 P.M.of the medication storage area. A black fanny pack was observed that contained an epi-pen. Direct care staff 3, stated that the fanny pack and epi-pen belonged to Client 1. Client 1's record review was conducted on 9/24/08 at 9:30 A.M. There was a physician's order for Client 1 for the "epi-pen 0.3 mg (micrograms) auto-inj(auto injector) to use for emergency allergy reactions" An interview was conducted with Licensed staff on 9/24/08 at 2:30 P.M.. ^stated that the epi-pen was supposed to be with Client! at all times. Licensed staff stated that the epi-pen was kept with the Client in> backpack. An interview and observation was conducted with the van driver on 9/24/08 at 2:45 P.M. Client 1 was observed sitting in the back set. The van driver stat*^ that Client 1 did not earn/ a j backpack., _ continued to state that! vas | unaware that the Client was allergic to bee stings j and had never seen an epi-pen and would not i know how to use it. J i The Licensed staff acknowledged that Client 1 did i not have an epi-pen on > person.' also ! acknowledged that the direct care staff needed to i be instructed on the purpose and use of the j epi-pen. j 1.b. Client 1's record review was conducted on : 9/24/08 at 9:30 A.M.. The health care plan titled i W331 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G2PE11 Facility ID: CA090000771 If continuation sheet Page 2 of 9 DEPARTMENT OF HEALTH AND HUM SERVICES CENTERS FOR MEDICARE & MED. ,_ SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 05G376 PRINTED: 10/03/2008 FORM APPROVED OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 09/25/2008 NAME OF PROVIDER OR SUPPLIER ORIENTE HOUSE STREET ADDRESS, CITY, STATE, ZIP CODE 3081 ORIENTS DRIVE VISTA, CA 92083 (X4)ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES I ID (EACH DEFICIENCY MUST BE PRECEDED BY FULL : PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) : TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE W342 W377 W383 Continued From page 4 backpack. continued to state that' _ was j unaware that the Client was allergic to bee stings > and had never seen an epi-pen and would not j know how to use it. i | The Licensed staff acknowledged that Client 1 did j not have an epi-peirom person.! also j acknowledged that the direct care sian needed to | be instructed on the purpose and use of the j epi-pen. j 483.460(0(1) DRUG STORAGE AND : RECORDKEEPING j The facility must store drugs under proper : conditions of sanitation. j This STANDARD is not met as evidenced by: Based on observation and interview, the facility failed to store medications under proper conditions. As a result topical medication and internal medications were stored together. Findings: During the medication audit and inspection on 9/22/08 at 6:45 P.M., creams and ointments (topical medication) were observed stored in a basket that also contained nose spray, eye drops and eardrops (internal medications). The Direct care staff 3 was interviewed, on 9/22/08 at 6:45 P.M.. acknowledged that internal medications and external medications should not have been stored together. 483.460(l)(2) DRUG STORAGE AND RECORDKEEPING Only authorized persons may have access to the W342I W377 W383J The facility shall store drugs under proper condition of sanitation. The Nurse Consultant has inserviced the med qualified staff to ensure that internal and external medications are not stored in the same containers. The Director of Residential Services, Nurse Consultant and Pharmacy Consultant shall ensure continued compliance by random quality assurance audits and direct observation. 9/24/08 Only authorized persons shall have access to the keys to the drug storage area. All staff have been re-inserviced 9/25/08 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G2PE11 Facility ID: CA090000771 If continuation sheet Page 5 of 9 DEPARTMENT OF HEALTH AND HIUM' SERVICES CENTERS FOR MEDICARE & MED, ^ oERVICES PRINTED: 10/03/2008 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER ORIENTE HOUSE (X4) ID PREFIX TAG (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 05G376 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) W 383 | Continued From page 5 ; I keys to the drug storage area. i This STANDARD is not met as evidenced by: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETEDA. BUILDING B. WING ID U9/Z{3/2008 STREET ADDRESS, CITY, STATE, ZIP CODE • 3081 ORIENTE DRIVE VISTA, CA 92083 PROVIDER'S PLAN OF CORRECTION PREFIX i (EACH CORRECTIVE ACTION SHOULD BE TAG | CROSS-REFERENCED TO THE APPROPRIATE | DEFICIENCY) w 383 1 regarding this regulation and the need for compliance due to safety concerns. : The Director of Residential Services, Nurse Consultant and shall ensure continued compliance by Base on observation and interview the facility failed to ensure only authorized persons had access to the control medication key. As a result 1 of 3 sampled clients ( Client 3) had access to the control medication key. Findings: random quality assurance audits and direct observation. \ Client 3 was admitted to the facil!t" V26/93 with i the diagnosis that included Per the I Client Identification sheet. On 9/23/08 at 7:00 turn the lock on the and Emergency information A.M. Client 3 was observed to drawer that contained the control medication key then opened the drawer. Client 3 placed a container for dentures in the drawer, then closed the drawer and went back to ^bedroom. It was observed the control medication key was in the drawer. On 9/24/08 at 8:00 A.M. Direct care staff 2 was . interviewed. stated that if the drawer is unlocked a staff member would be in possession W455 of the control medication key. Direct care staff 2 stated that i ' passed the morning medication ''. on 9/23/08 and .did not have the control medication key in possession. 483.470(l){1) INFECTION CONTROL | There must be an active program for the prevention, control, and investigation of infection and communicable diseases. W 455 The facility shall provide an active program for the prevention, control and investigation of infection and communicable diseases. The House Manager has replaced the (X5) COMPLETION DATE 10/1/08 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G2PE11 Facility ID: CA090000771 If continuation sheet Page 6 of 9 DEPARTMENT OF HEALTH AND HUM SERVICES CENTERS FOR MEDICARE & MED> ^ SERVICES FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 05G376 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 09/25/2008 NAME OF PROVIDER OR SUPPLIER ORIENTE HOUSE STREET ADDRESS, CITY, STATE, ZIP CODE 3081 ORIENTE DRIVE VISTA, CA 92083 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES i ID (EACH DEFICIENCY MUST BE PRECEDED BY FULL ! PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) j TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) toothbrushes for all clients and has replaced their cover. The Director of Residential Services and shall ensure continued compliance by random quality assurance audits and direct observation. (X5) COMPLETION DATE W 455 i Continued From page 6 This STANDARD is not met as evidenced by: Based on observation and staff interview, the facility failed to ensure that tooth brushes were stored in a manner to prevent contamination for 1 of 3 sampled clients (1) and 1 randomly observed client (4). In addition, Client 1's tooth brush was observed to have flat, spread out bristles with white dry residue caked inbetween. Findings: Client 1 was admitted to the facility with diagnosis that included,* Per the Client Identification and Emergency inrormation sheet, The individual service plan annual review dated 3/13/08 indicated Client 1 does not brush his teeth thoroughly. Client 4 was admitted tojhe facility 3/7/96 with the diagnosis of I per the Client Identification ana cmciyciicy imormation sheet. On 9/22/08 at 3:58 P.M., an observation of the client's grooming kit was conducted with Direct Care Staff 1. Client 1's tooth brush was observed to have flat, spread out bristles with white dry residue caked in between. It was stored uncovered inside a plastic grooming kit with an electric razor and deodorant. Client 4 's tooth brush was observed stored uncovered inside a plastic grooming kit with deodorant W 455 An interview with the afSTOOP.M. Tne was conducted on y/^^/uo * stated that the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G2PE11 Facility ID: CA090000771 If continuation sheet Page 7 of 9 DEPARTMENT OF HEALTH AND Hf SERVICES CENTERS FOR MEDICARE & MEDIUAlD SERVICES PRINTED: 10/03/2008 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 05G376 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 09/25/2008 NAME OF PROVIDER OR SUPPLIER ORIENTE HOUSE STREET ADDRESS, CITY, STATE, ZIP CODE 3081 ORIENTE DRIVE VISTA, CA 92083 (X4)ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE W455 W483 Continued From page 7 toothbrushes should have been covered, further stated that Client 1's toothbrush needed to be replaced. 483.480(d)(2) DINING AREAS AND SERVICE The facility must provide table service for all clients who can and will eat at a table, including clients in wheelchairs. This STANDARD is not met as evidenced by: Based omjbservation, the facility failed to ensure 1 of 3 sample clients (1) received appropriate staff modeling to assist in eating skills when staff did not sit at the table with the Client. As a result Client 1 had put several spoonfuls of cereal in his mouth at one time causing the cereal to drip out. Findings: Per the Client Identification and Emergency Information sheet. Client t"Was admitted to the _ facility with diagnosis that included, 1 On 9/23/08 at 7:00 A.M., during the breakfast meal, Clients 1 was observed to be sitting at the dinning room table by eating breakfast. The direct care staff 1 stood directly across the table from Client 1 with >arms resting on the back of the dinning room chair. Direct care staff 1 verbally redirected Client 1, three different f'^es, to "slow down, take small bites and to use lapkin". Direct care staff 1 stated that Client 1 needed to be watched during meal times because1 would "stuff a lot of food" in mouth at one time. An interview was conducted with the > • W455 W483 The facility shall provide table service for all clients who can and will eat at a table. The staff has been directed to sit with the clients while they are eating all meals, including when utilizing the breakfast bar in the morning. The Director of Residential Services and " hall ensure continued compliance by random quality assurance audits and direct observation. 9/25/08 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G2PE11 Facility ID: CA090000771 If continuation sheet Page 8 of 9 DEPARTMENT OF HEALTH AND HUV SERVICES CENTERS FOR MEDICARE & MED ,,^ SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 05G376 PRINIkU: 1U/U3/ZUUO FORM APPROVED OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 09/25/2008 NAME OF PROVIDER OR SUPPLIER ORIENTE HOUSE STREET ADDRESS. CITY, STATE, ZIP CODE 3081 ORIENTE DRIVE VISTA, CA 92083 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES i ID (EACH DEFICIENCY MUST BE PRECEDED BY FULL i PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) ! TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE W 483 Continued From Dane R " ..... /on i 3/^<t/vo at a: ID A.M.. The< stated that the direct care staff should sit with the clients during meal times. W483! FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G2PE11 Facility ID: CA090000771 If continuation sheet Page 9 of 9 DEPARTMENT OF HEALTH AND Hlr SERVICES CENTERS FOR MEDICARE & MEDICAlD SERVICES PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER ORIENTE HOUSE (X4) ID PREFIX TAG WOOO /^£r<L-~@ W111 (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY IDENTIFICATION NUMBER: COMPLETED A. BUILDING 05G376 BWING 12/14/2007 STREET ADDRESS, CITY, STATE, ZIP CODE 3081 ORIENTE DRIVE VISTA, CA 92083 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) INITIAL COMMENTS -The following reflects the findings of the California Department of Public Health during a FUNDAMENTAL survey. Representing the California Department of Public Health: Marie Falcon, HFEN. Then census of the facility during the survey was 6 clients. The sample size was 3 clients. 483.410(c)(1) CLIENT RECORDS The facility must develop and maintain a recordkeeping system that documents the client's health care, active treatment, social information, and protection of the client's rights. This STANDARD is not met as evidenced by: Based on interview and record review, the facility failed to develop and maintain a record keeping system that documented the doctor's reviews of all laboratory test results, for 1 of 3 sampled clients (Client 3), who was taking Warfarin/Coumadin, a blood thinner. There was no indication that an abnormal test for blood-clotting factors was reviewed by the physician. Findings: On 12/1/07 at 1:00 P.M. a review of Client 3's clinical records was initiated. Client 3 was admitted to the facility on 3/7/06, with a history of heart murmur, per the facility face sheet. ID PREFIX TAG WOOO W111 In Annnst 7007, Client 3 was diagnosed with according to the Annual """ Progr«,,, ,\CVicw Health form dated 9/24/07. The (U^ PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) [fTlrrGlETw'Elnlj . ^ — — — • — i i ,n\ y [| JAN 14 2008 ]VJ LICENSING AND CERTIFICATION SAN DIEGO DISTRICT OFFICE SOUTH - — __ ' RfO b $\Mtf* -rra/T \*> Y&£>r>n/\<f?' ioU -£/"/" wlrvfi to' \^ ' 6i/H~rZ<£' _i i _!—-, £Xll.n i v~~(juCwTo ~TZ')"»6<MU/U/"'t/U> w\ ]<$>£> , \0 0DTZVVO \&\&*tA dnMAWftAfl&h'OY] •(AL> MA/ C/VV 1 . 1 D msdzpf fiT %<S£>\ k-CMA^^ f\ \ 1 / * ^*^s i| v \L>C<^^ \ C^^V*^ * /x^*v |tx 1 1^«i -^i^u/iA^i^lvt^ ^O c3>k-m\ / . 1 | » /\ />J f\ I 1 1 A^ &A • JT*^-^ IfAaJ\j^(/\ (JMjU(k™\C/w\^ K/V*' "fp£> (/Mrb?- AJ •^ \1^ (X5) COMPLETION DATE 1 1410*5 i | LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be exdused from correcting providing it is deternirfed that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5S0511 Facility ID: CA090000771 If continuation sheet Page 1 of 6 DEPARTMENT OF HEALTH AND HI' SERVICES CENTERS FOR MEDICARE & MEDICAlD SERVICES PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 05G376 BWING 12/1^1/2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE (X4) ID PREFIX TAG W111 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 December 2007 physician's orders indicated that Client 3 was started on Coumadin on 8/23/07, and was currently being administered 4.5 milligrams of Coumadin daily. A laboratory report, dated 10/2/07, was noted in the record and indicated that the INR (coagulation/blood clotting ratio) was 2.7, which was within the normal therapeutic range according to the laboratory's normals range of 1.7 to 3.0. There was no indication on the laboratory report document that the physician had seen the lab result or that the physician had been notified of the lab results. Also noted in the record, was a laboratory report from a different lab, dated 10/9/07, which showed the INR test results were 1.8, which was below the laboratory's documented therapeutic range of 2.0 to 3.0. There was no indication on the laboratory report document that the physician had reviewed the lab result or had been notified of the laboratory results. On 12/13/07 at 1:35 P.M. an interview was conducted with the facility nurse. The nurse said that the physician had sent Client 3 to the laboratory directly after a doctor's visit and the laboratory results were sent directly to the physician's office. According to the nurse, the physician was supposed to review the results, sign the document, and send the forms to the corporate office along with any new orders. On 12/14/07 at 2:00 P.M., another interview with the facility nurse was conducted. The facility nurse stated that the corporate office had not yet received signed copies of the 10/2/07 and 10/9/07 laboratory reports from the physician's office. ID PREFIX TAG W111 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5S0511 Facility ID: CA090000771 If continuation sheet Page 2 of 6 DEPARTMENT OF HEALTH AND HI SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETEDA. BUILDING nur- JTC B. WING05G376 —12/1*1/2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE°™ ^™r (X4) ID PREFIX TAG W111 W263 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 I stated that' had no way of knowing if the physician had received and reviewed the 10/9/07 abnormal laboratory report. The facility nurse also stated that' believed Client 3 may have had blood clotting tests conducted in November and December 2007, but had no evidence of the results. The nurse acknowledged that there was a "systems problem" with getting laboratory results and assuring that the physician had reviewed lab test results. 483.440(f)(3)(ii) PROGRAM MONITORING & CHANGE The committee should insure that these programs are conducted only with the written informed consent of the client, parents (if the client is a minor) or legal guardian. This STANDARD is not met as evidenced by: Based on interview and record review, the facility failed to ensure that a current written informed consent for two\ ledications was obtained, for 1 ot 3 sampled clients (Client 2). Findings: A review of the Client 2's clinical record was initiated on 12/13/07 at 9:00 A.M. Client 2 was admitted to the facility on 8/1 1/97, according to the farp. sheet. Client 2 's medications included a , / . . _ •> . ,, . medication Bordered fort > . .. pehaviors, and «. i ' Dedication used for per the physician's orders dated November 2007. One signed parental consent for the _ administration off nc " was ID PREFIX TAG W111 W263 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ~~Vn\6 C\\£YV\|S> W\5|T\ft<sr \z> (j(CC&?&€'&- (Avy/l-Vfat^' b \)0 Ift-TfrK^yvtM^ OJJft/([fov> \&- V- \ V I v)/X\J/, \3&AV\. ^x"H/t "^ I •W' I ^ ~ . £^Q/WfDV*>W-~v^X \ | -£/{\£)\Jj( (/^(\ C,0^)£>~&V(/\^> C">'&. f) \) T#l \ >0 C-^l . (X5) COMPLETION DATE i \ | li 1 D Q 1*1 ^ FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5S0511 Facility ID: CA090000771 If continuation sheet Page 3 of 6 DEPARTMENT OF HEALTH AND HI SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETEDA. BUILDING nc/— I7C B- WING05G376 12/1<1/2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE™ rT™r (X4) ID PREFIX TAG W263 W352 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 found. The document indicated that the consent was valid for a period of 1 year. However, the consent was dated 10/26/04, more than three years prior. On 12/13/07 at 12:30 P.M., an interview was conducted with the facility nurse, who acknowledged that the consent was outdated and not valid, and that, a new consent should have been_pbtained before administering the -medications. 483.460(f)(2) COMPREHENSIVE DENTAL DIAGNOSTIC SERVICE Comprehensive dental diagnostic services include periodic examination and diagnosis performed at least annually. This STANDARD is not met as evidenced by: Based on interview and record review, the facility failed to ensure that, 1 of 3 sampled clients (Client 1), received annual dental examinations. Findings: A review of Client 1's clinical record was conducted on 12/13/07 at 9:00 A.M. Client 1 was admitted to the facility on 1 1/29/04, with diagnoses that included a' According to the client's October 2007 monthly summary of medical care, the last time that the client was evaluated by a dentist was on 8/5/05, more than two year ago. An interdisciplinary note, dated 10/6/05, indicated that the dentist had refused to provide service due to a lack of insurance coverage. And that, the facility plan was to follow-up in 4-6 weeks. No ID PREFIX TAG W263 W352 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ^fvWTzCV Ct& PfiVA*^1^^ VxX±> \)£-&f\ ^(s^cfyw-fC^ "T#~* , \ \ GU>£wO Wevcb W\J \AU < V-W*v Vii VK -rA«v \ lub 2^6^06 (X5) COMPLETION DATE i|H\P* V FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5S0511 Facility ID: CA090000771 If continuation sheet Page 4 of 6 DEPARTMENT OF HEALTH AND HI SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER ORIENTE HOUSE (X4) ID PREFIX TAG W352 W438 (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: A. BUILDING 05G376 BWING STREET ADDRESS, CITY, STATE, ZIP CODE 3081 ORIENTE DRIVE VISTA, CA 92083 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 additional follow-up the records. documentation was found in The facility nurse was interviewed on 12/13/07 at 9:40 A.M. She stated that the client was in need of dental work and was late f< dental exam due to insurance issues. 483.470(h)(1) EMERGENCY PLAN AND PROCEDURES The facility must develop and implement detailed written plans and procedures to meet all potential emergencies and disasters such as fire, severe weather, and missing clients. This STANDARD is not met as evidenced by: Based on observation and interview, the facility failed to maintain an adequate supply of emergency water to meet the clients and staffs minimal water needs, for three days in the event of a disaster. Findings: On 12/1 1/07 at 6:10 A.M. a joint inspection of the emeraenrw water cnnni\/ \A;OC rnnrtunted with the The facility was observed to have 3.3 gallons of emergency water set asWp =>nd designated for emergency use. The tated that she understood that 24 gallons of water would be needed to supply their 6 clients and 2 staff members with adequate emergency water for a 3 day period. On 12/12/07 at 6:30 A.M., during a second joint inspection of emergency supplies with the> another 4 gallons of emergency water was ID PREFIX TAG W352 W438 (X3) DATE SURVEY COMPLETED 12/14/2007 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 1 \\C f@.C&'fato6rt-d£C4 CWtfiutf £>r \P\AF&S W^> ve&v\ (X5) COMPLETION DATE , I4|<* *" FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:5S0511 Facility ID: CA090000771 If continuation sheet Page 5 of 6 DEPARTMENT OF HEALTH AND HI SERVICES CENTERS FOR MEDICARE & MEDICAlD SERVICES PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETEDA. BUILDING 05G376 BWING 12/1<1/2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE (X4) ID PREFIX TAG W438 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 5 located. The tsaid that she had not been aware that the additional water existed. The stated that in a disaster they could also use the 116 gallons of water in their hot water tank. However, there was no system or policy and procedure in place for testing for the safety of the tank \watar_ for purjfyjng it, or for transporting it. The acknowledged that they did not have 24 gallons of water readily available as needed. ID PREFIX TAG W438 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5S0511 Facility ID: CA090000771 If continuation sheet Page 6 of 6 Department of Health and Human Servicr Centers for Medicare & Medicaid Servicv Form Approved OMB NO. 0938-0390 Post-Certification Revisit Report Public reporting for this collection of information is estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing the burden, to CMS, Office of Financial Management, P.O. Box 26684, Baltimore, MD 21207; and to the Office of Management and Budget, Paperwork Reduction Project (0938-0390), Washington, D.C. 20503. (Y1) Provider/ Supplier /CLIA/ Identification Number 05G376 (Y2) Multiple Construction A. Building B. Wing Name of Facility ORIENTE HOUSE (Y3) Date of Revisit 1/14/2008 Street Address, City, State, Zip Code 3081 ORIENTE DRIVE VISTA, CA 92083 This report is completed by a qualified State surveyor for the Medicare, Medicaid and/or Clinical Laboratory Improvement Amendments program, to show those deficiencies previously reported on the CMS-2567, Statement of Deficiencies and Plan of Correction that have been corrected and the date such corrective action was accomplished. Each deficiency should be fully identified using either the regulation or LSC provision number and the identification prefix code previously shown on the CMS-2567 (prefix codes shown to the left of each requirement on the survey report form). (Y4) item (Y5) Date (Y4) Item (Y5) Date (Y4) Item (Y5) Date Correction Completed ID Prefix W0111 01/14/2008 ReS-# 483.41 0(c)(1) LSC Correction Completed ID Prefix W0438 01/14/2008 Re9-# 483.470(h)(1) LSC Correction Completed ID Prefix Reg.# LSC Correction Completed ID Prefix Reg. # LSC Correction Completed ID Prefix Reg.# LSC ^x'" Reviewed By Reviewed By State Agency ^ (j ^ \ — v Reviewed By Reviewed By CMSRO Followup to Survey Completed on: 12/14/2007 / Correction Completed ID Prefix W0263 01/14/2008 Reg.# 483.440(f)(3)(ii) LSC Correction Completed ID Prefix Reg.# LSC Correction Completed ID Prefix Reg. # LSC Correction Completed ID Prefix Reg. # LSC Correction Completed ID Prefix Reg.# LSC s^^_,? — -if >> \ \Date: / StertiXurQ <Mwry]j&or\ Correction Completed ID Prefix W0352 01/14/2008 Re9 * 483,460(f)(2) LSC Correction Completed ID Prefix Reg.# LSC Correction Completed ID Prefix Reg.# LSC Correction Completed ID Prefix Reg.# LSC Correction Completed ID Prefix Reg. # LSC \ Date: , / (/ ~ '^-L_N~y " iv''Date: Signature of Surveyurr Date: Check for any Uncorrected Defici Uncorrected Deficiencies (CMS sncies. Was a Summary of -2567) Sent to the Facility? YES NQ Form CMS - 2567B (9-92)Page 1 of 1 Event ID: 5S0512 California Department of Public Heal PRINTED: 12/05/2007 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING B. WINGCA090000771 11/16/2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORIENTE HOUSE 3081 ORIENTE DRIVE VISTA, CA 92083 (X4) ID PREFIX TAG BOOO SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Initial Comments The following reflects the findings of the California Department of Public Health during the investigation of one (1) entity reported incident. Entity reported incident: CA00131794 Representing the Department: Aty Knooren, HFEN. The inspection was limited to the entity reported incident investigated and does not represent the findings of a full inspection of the facility. No deficiencies were issued for entity reported incident CA001 31 794 ID PREFIX TAG BOOO , PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ^ "\?l\-)fV7 (X5) COMPLETE DATE LABORATORY ERECTOR'S OR^ROVIDERSUPPLIER REPRESENTATIVE'S SIGNATURE 'TITLE (X6) DATE STATE FORM PP1811 California Department of Public Health PRINTED: 08/03/2007 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING B. WING CA090000771 NAME OF PROVIDER OR SUPPLIER ORIENTS HOUSE (X4) ID PREFIX TAG BOOO STREET ADDRESS, CITY, STATE, ZIP CODE 3081 ORIENTE DRIVE VISTA, CA 92083 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Initial Comments The following reflects the findings of the California Department of Public Health during the investigation of one (1) entity reported incident. Entity reported incident: CA00121728 Representing the Department: Aty Knooren, HFEN. The inspection was limited to the entity reported incident investigated and does not represent the findings of a full inspection of the facility. No deficiencies were issued for entity reported incident CA001 21 728 - ID PREFIX TAG BOOO (X3) DATE SURVEY COMPLETED 08/02/2007 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE LABORATORY DIRECTOR'S pR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE (X6) DATE STATE FORM If contin/atio^ she4t 1 of 1 DEPARTMENT OF HEALTH AND HUI.. CERVICES CENTERS FOR MEDICARE & MEDICAL-CERVICES PRINTED: 01/12/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER ORIENTE HOUSE (X4) ID PREFIX TAG WOOO W 124 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 05G376 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) INITIAL COMMENTS The following reflects the findings of the Department of Health Services during a FUNDAMENTAL survey. Representing the Department: Aty Knooren, HFEN. The census at the time of the survey was 6 clients. The sample size was 3 clients. 483.420(a)(2) PROTECTION OF CLIENTS RIGHTS The facility must ensure the rights of all clients. Therefore the facility must inform each client, parent (if the client is a minor), or legal guardian, of the client's medical condition, developmental and behavioral status, attendant risks of treatment, and of the right to refuse treatment. This STANDARD is not met as evidenced by: Based on interview and record review the facility failed to obtain informed consents for the use of cneiifev- -) Findings: for 2 of 3 sampled 1 . According to the client's face sheet, Client 2 was admitted to the facility on 1/26/93 with diagnoses that included Record review on 1/4/07 indicated that according to the physician order form dated 1 1/06, Client 2 had an order for f 5mg every dav for , and fo "~ ' (in lieu of 10 mg, two taoiets oam, ^,,~ tablet (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 3081 ORIENTE DRIVE VISTA, CA 92083 ID PREFIX TAG WOOO W124 4 * (X3) DATE SURVEY COMPLETED 01/04/2007 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DJEHl 11 ¥ E U Li FEB 1 6 2007 LICENSING AND CERTIFICATIOr- SAN DIEGO DISTRICT OFFICE SOU! C-l;*— t -4*7- <..,v.<;t_-H "**--« OJ W OC,i \ ^A (2*-Sf>ovA-Vl W<t- TW H^^n./^^.^. ^^^_^- <X5) COMPLETION DATE •O 1) H >|!'-7 LABORATORY/3IRE£IOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE ' <-> TITLE (X6) DATE _ 'fcfiAny deficiency-statement ending with an asterisk (*) denotes a deficiency which tf/fe institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GORG11 Facility ID: CA090000771 If continuation sheet Page 1 of 4 DEPARTMENT OF HEALTH AND Hb. CERVICES CENTERS FOR MEDICARE & MEDICAlu SERVICES PRINTED: 01/12/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER ORIENTE HOUSE (X4) ID PREFIX TAG W 124 (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER:A. BUILDING 05G376 BWING STREET ADDRESS, CITY, STATE, ZIP CODE 3081 ORIENTE DRIVE VISTA, CA 92083 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 (12-4-8) for inaDDrooriate behavior. The "consent for use of Dedications" forms dated 10/24/04 indicated that the consents were valid for a period of one year. The" >»~ was irnerv one acknowledged signed on an annu< lewed on 1/4/u/ at 3:00 r.ivi. that the consent was not al basis. 2. According to the client's face sheet, Client 3 was admitted to the facility on 7/17/89 with diagnoses that included Record review on 1/4/07 indicated that according to the physician order form dated 1 1/06, Client 3 had an order for Ambien 10 mg for sleep, if no sleep in 3 nights. There was no evidence of a consent found in the client's record. The was interviewed on 1/4/07 at 3:00 P.M. W261 She acknowledged that the medication did not have a consent in the record. 483.440(f)(3) PROGRAM MONITORING & CHANGE The facility must designate and use a specially constituted committee or committees consisting of members of facility staff, parents, legal guardians, clients (as appropriate), qualified persons who have either experience or training in contemporary practices to change inappropriate client behavior, and persons with no ownership or controlling interest in the facility. This STANDARD is not met as evidenced by: ID PREFIX TAG W 124 W261 (X3) DATE SURVEY COMPLETED 01/04/2007 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) :ti:7r;,s;;:;\a_vv . C"*£e*vJt- a^Ji ft if" f-olVo\x> v/i-p tol fj^vL-,1 1 T1~* •* i* p\AX»Y'<_J 1 d^as — - v^^v^(Wv.—^ ' (X5) COMPLETION DATE M"1 *" FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GORG11 Facility ID: CA090000771 If continuation sheet Page 2 of 4 DEPARTMENT OF HEALTH AND HUtv. SERVICES CENTERS FOR MEDICARE & MEDICAlt, SERVICES PRINTED: 01/12/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETEDA. BUILDING 05G376 BWlNG 01/0't/2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE (X4) ID PREFIX TAG W261 W352 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 Based on interview and record review the facility failed to have a community representative participate in the human rights committee. The community representative is the person on the committee without ownership or controlling interest in the facil ty. Findings: Record review of the quarterly human rights (HR) committee forms on 1/4/07 at 3:00 P.M. indicated that there were no signatures of the facility's community representative. An interview with the director of adult services was conducted on 1/4/07 at 5:00 P.M. The director acknowledged that they did not have a community representative on the the HR committee. 483.460(f)(2) COMPREHENSIVE DENTAL DIAGNOSTIC SERVICE Comprehensive dental diagnostic services include periodic examination and diagnosis performed at least annually. This STANDARD is not met as evidenced by: Based on interview and record review the facility failed to provide annual dental diagnostic services for one sampled client (1). Findings: According to the client's face sheet, Client 1 was admitted to the facilitv on a/on/m wjth diagnoses that included^ Record review on 1/4/07 at 10:00 A.M. indicated ID PREFIX TAG W261 W352 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) J c.o^«/aHtt. v^e^W-v- W vvty.-V H*2- - V+ v^~, •*-/ «lv*~~~ «, V~+<~ ^1^ ( |° Dl^ecTb*- oF APUL.TS £esfow<,x*u<- **- COM>^^ °? **-Co*MVTTei , , , - », r O 1 1 C-VA. \~ "TT ( C- t\Y"«^x-T *-x^i vO<X> Vl v*.£i "yTW C^flpro\/£^\ 'TIT" O<-V^"TZ&.\ "prC-eC*" Vv-fcwA~ > ^ ,u c.vcWV u^ <U^i ofCW «^?DU-C- *o oW-W^w rtco^— t^J^A . J / J ^^ ^ ^ .VAA^u^. ,^ 6**& Vi^-UA «««,> «vla,t.-kj o <^~ s ••^A f ' J 'p.VJ Y-t^p«v^V>w«- T**r ° * iAivrt>/^i "TX«TW-tv^ (X5) COMPLETION DATE 1 so 1 ^h ^ A^S l*^-/Lt i-U FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GORG11 Facility ID: CA090000771 If continuation sheet Page 3 of 4 DEPARTMENT OF HEALTH AND HIL SERVICES CENTERS FOR MEDICARE & MEDICAlu SERVICES PRINTED: 01/12/2007 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 05G376 B.W1NG A^m,01/0^1/2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE (X4) ID PREFIX TAG W352 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 that Client 1 had last seen the dentist on 8/2/05, according to the dental office form. Comments from the dentist indicated that Client 1 had "chronic periodontal disease" with "moderate tartar present" and that needed anesthesia to be treated. Thej^.. *was interviewed on 1/4/07 at 3:00 P.M. bne acknowledged that the annual dental visit was overdue. ID PREFIX TAG W352 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GORG11 Facility ID: CA090000771 If continuation sheet Page 4 of 4 PRINTED: 03/29/2006 FORM APPROVED California Department of Hea STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER ORIENTE HOUSE (X4) ID PREFIX TAG NOOO N295 th Services \ ) (X1) PROVIDEFi/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY IDENTIFICATION NUMBER: COMPLETEDA. BUILDING B WINGCA090000771 03/29/2006 STREET ADDRESS, CITY, STATE, ZIP CODE • ' . 3081 ORIENTE DRIVE VISTA, CA 92083 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Initial Comments The following reflects the findings of the Department of Health Services during a complaint investigation. Complaint Number(s): CA00075869 Category: Unusual Occurrence Inspection was limited to the specific complaint(s) investigated and does not represent the findings of a full inspection of the facility. Representing the Department of Health Services: Patricia Horn-Seuferer, HFEN. CCR TITLE 22 DIV5 CH8.5 ART4 -76923(a) Unusual Occurrences (a) Occurrences such as but not limited to, epidemic outbreaks of any disease, prevalence of communicable disease, whether or not such communicable disease is required to be reported by Title 17, California Administrative Code, Section 2500 or infestation by parasites or vectors, poisonings, fires, major accidents, deaths from unnatural causes or other catastrophes which threaten the safety or health of clients, personnel or visitors are deemed to be unusual occurrences and shall be reported by the facility within 24 hours either by telephone, with written confirmation, or by telegraph to the local health officer and the Department. This RULE: is not met as evidenced by: Based on observation, interview, and record review, the facility failed to notify the Department of an unusual occurrence within 24 hours. Findings: DCS 1 was interviewed on 3/28/06 at 5:45 P.M. ID PREFIX TAG NOOO N295 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) _— — - — r~7p~T~ri fr!j\ £ C E 5 w ^ \r\\li n\r~ ~~^ u i ^\^^\L^J^^ \ \ 1!TNS!NG ANO L.I" H I i" ^jt> • ' • ~' \ _|JV--- !.:.^ ',_'..„:-.,. ^ t"|pT At {'({*[ '^OU'TH J ,..: t-~-^~~~~~r~^~ ' . r M . r ,. , \\\C^ |4^~Tnli>-^/^ii"N 'h\\. \<f^f 4t) ~^V » >P^ VrfVOeC'Vf'fe' r s ~ I T I -/^,JfoS Z2JXtL&J\ -Wl (A. & tW\5> . \ r h. A 1-1- *-Yf\Iltj£<->.Jj}\f5&CTZ'r" 0T nO^M ' (( JUf/ f *yD?&.<*\V^jt W Cv&(kf& ty[^ ^r (X5) COMPLETE DATE ^h/^ ' • I . i i | Ji^^vl'<^w-te A/Q^^PP<Z?v)1fUXn^^i v- ID Jtotwtt^ . * TITLE (X6) DATELABORATORY DRECTOR'S OR PR R/SUPPLIER REPRESENTATIVE'S SIGNATUR! STATE FORM 16f4 FORM APPROVED California Department of Health Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETEDA. BUILDING B WINGCA090000771 03/29/2006 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORIENTE HOUSE 3081 ORIENTS DRIVE VISTA, CA 92083 (X4) ID PREFIX TAG N295 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From Page 1 She stated she was present in the house on 1/1 1/06 at approximately 8:00 A.M. Client A was aggressive earlier in the morning. The client was not a morning person. DCS had been trying to get Client A to get up and take a shower since 6:45 A.M. The client finally went into the bathroom at 8:00 A.M. All of the other clients were. ready to leave for the day program. DCS told the clienl no longer had time to take a shower because they needed to leave for the day program. The client hit the walls in the bathroom several times. The client then putf left hand through the window in the bathroom. The left wrist sustained a laceration and was bleeding. She wrapped the client ' s wrist in a towel to stop the bleeding and summoned another DCS to assist her. was administered to the client to cainv* " down. The Director of Residential Services, the licensed nurse, and the behavior specialist were all notified of the incident. The behavior specialist immediately came to the house to assist. The licensed nurse arrived at the house as the DCS and the behavior specialist were escorting the client out of the house and into the van for the ride to the local emergency room. The client was calm by the time they reached the emergency room. The client was cooperative with the treatment. The client received 8 stitches to the left wrist. The master bathroom was observed on 3/28/06 at 5:55 P.M. with DCS 1. A frosted glass window, measuring approximately four feet by two feet, was observed in the bathroom. A smaller window that could open was located below the solid paned window. DCS 1 reported the windows had been replaced with tempered glass so the windows were more difficult to break. In addition, the window in the client ' s bedroom had also been replaced with tempered- - _. r I ID PREFIX TAG N295 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE ' CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) , . . (X5) COMPLETE DATE STATE FORM If continuation sheet 2 of 4 California Department of Health Services I-IMINICU: FORM APPROVED •• STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING B. WINGCA090000771 03/29/2006 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORIENTE HOUSE 3081 ORIENTE DRIVE VISTA, CA 92083 (X4) ID PREFIX TAG N295 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From Page 2 glass. Client A was observed in^ i room on 3/28/06 at 6:00 P.M. paced in room, tossing a football in the air and catcning it. communicated verbally speech was clear, oointed to a healed one-inch cut to the inner left wrist. lated did not have a loss of function to tfiis arm or hand. denied any pain. Client A ' s medical record was reviewed on 12/06/05. was admitted to the facility on . 11/29/04 witn a diagnosis that included .... (a form off ft according to the face sheet. The incident was documented on the behavior observation sheets. According to the emergency room records, the client was seen in the emergency room on 1/11/06 for a laceration, which required suturing. The client was discharged on the same day with instructions to follow up with irimary care physician. According to the physician ' s orders, the client was prescribed medications for behaviors. According to the behavior plan, dated 7/30/02, the client displayed , behavior to include ignoring staff, moodinessT hitting or kicking objects, picking at scabs and eating them, and saying " leave me alone " , " don't bug me " , and " you're not my boss. " A second behavior plan, dated 7/30/0? '"Boated the client-displayed behaviors of* __ to include hitting, biting, kicking, throwing objects, poling holes in objects, and pinching. The facility incident report was reviewed. Documentation indicated the incident was ID PREFIX TAG N295 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE STATE FORM 021199 If continuation sheet 3 of 4 California Department of Health Services PRINTED: 03/29/2006 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING B. WINGCA090000771 03/29/2006 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE, ZIP CODE ORIENTE HOUSE 30ff1 ORIENTS DRIVE VISTA, CA 92083 (X4) ID PREFIX TAG N295 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From Page 3 reported to the regional center the responsible party. There was no documentation to indicate the unusual occurrence was reported to the Department. The Director of Residential Services was interviewed on 3/28/06 at 5:00 P.M. She acknowledged the unusual occurrence was not reported to the Department. ID PREFIX TAG N295 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE STATE FORM If continuation sheet 4 of 4 The Concerned Homeowners Dana Matas and John McConnin February 10, 2009 TERI Inc. was awarded: $800,000 federal Community Development Block Grant 600,000 from HUD These funds were intended to provide affordable housing to low income individuals AND to provide for “moderate or substantial rehabilitation” to a neighborhood. Charming cottage style single story Canterbury model highly upgraded both inside and out. Resort style yard with salt water pool and spa, play area for children, plus additional side yard. Built in BBQ and dining area. If you demand the finest...this is it. Previous owner spared no expense... Actual Ad Granite countertops, hardwood floors, and GE Monogram appliances. Play structure with foam padding base, Salt water pool and spa HOA Fees ($199/mo)$2388/yr Assessment District 2002-01:$1,447.54/yr Carlsbad Unified CFD #3:$908.22/yr _______________________________________ Total $4743.76/yr Funds that could otherwise be used to help other developmentally disabled individuals. Single Story, 3BRs 2524 Davis Ave $370,000 1055 Laguna $419,000 1099 Buena Vista $425,000 2735 Cypress Hill Rd $429,000 1735 Rogue Isle Ct.$450,000 3440 Donna Dr $490,000 3051 PASEO ESTRIBO $469,000 5BRs 3311 Rancho Carrizo $590,000 6BRs 6071 Paseo Pradera $599,000 “We bought here for the same reasons you did; it’s a lovely community…” --Cheryl Killmer, TERI CEO “[TERI] agrees to use all funds provided by the City …pursuant to the provisions of this Agreement, the Scope of Work,…and in accordance with the terms of the Annual Consolidated Plan.” “[TERI] also agrees to adhere to the terms of the City’s CDBG Application…” Priority Conserve and Rehabilitate Existing Housing Stock Implementation HP-3 Provide Moderate or Substantial Rehabilitation: The City may provide funding to assist in moderate or substantial rehabilitation of existing housing stock. Although the majority of the City’s housing stock is relatively new, a portion of the homes near the Village are is aged and in need of rehabilitation. Proposed project for CDBG funding “must meet at least one of the local objectives” 1.Affordable Housing –Rehabilitation 2.Social Services –Service providers 3.Social Services –Children and adults By purchasing the BRESSI home, TERI no longer qualifies for CDBG Funding. Document Review of Local Objectives “…every project proposed for CDBG funding must meet at least one of the local Community Development Objectives, which are: 1.Affordable Housing: -Provide direct benefit to lower income persons through the provision of additional affordable housing units in Carlsbad; -Provided shelter or services to homeless or near homeless persons/families which result in an improved situation through employment, permanent housing, treatment of mental, or substance abuse problems, etc.; and, -Provide direct assistance to lower income households to prevent or eliminate residential Building or Municipal Code violations and/or improve the quality of housing units in Carlsbad through residential rehabilitation programs. “The proposed project meets Local Community Development Objectives through TERI provision of residential services to children and adults with Special Needs (100% of our clientele). “ --TERI, Inc. This project only serves four men, not children. HUD loan approved for six residents not four (six-bed). They tell us four. HUD loan approved for 100% Carlsbad residents. They tell us they may be from other cities. Both applications state no violations exist. We found tons of violations. Changes to agreement require prior written consent from HUD. No written notices provided. Application Review Process i.Accessibility of activity for use by Carlsbad clients. May not be from Carlsbad ii.Extent to which proposed activity benefits low income persons/households. Only 4 people iii.Extent to which proposed activity benefits low income Carlsbad households. Negative impact. No rehabilitation needed in Bressi Ranch Neighboring home fell out of escrow Plans to expand home against HOA rules (undermines CC&Rs) City out $13,000 in property tax revenues every year. Suggestions: TERI sell the house in Bressi and use funds to purchase in a neighborhood that needs rehabilitation; or, TERI refund the CDBG funds altogether And, Investigate TERI’s contractual inconsistencies and violations before approving further funding of any kind. www.TheConcernedHomeowners.org