Montgomery Springs Manor

Based on record review, the licensee did not comply with the section cited above in S3, a cook, not having food preparation training on file which poses a potential health and/or personal rights risks to persons in care.

Based on records review, the licensee did not comply with the section cited above in not having doctor's orders for half bed rails for 2 residents which pose a potential safety and/or personal rights risks to persons in care.

Based on records review, the licensee did not comply with the section cited above in residents current medications not having doctor's orders on file which pose an immediate health and/orr personal rights risks to persons in care.

Based on records review, the licensee did not comply with the section cited above in residents' (R1 and R2) LIC602A Physician's Report/medical assessments over a year old which pose a potential health, safety or personal rights risks to persons in care.

Based on record review, the licensee did not comply with the section cited above in S2 not having LIC501 on file which poses a potential safety and/or personal rights risks to persons in care.

Based on record review, the licensee did not comply with the section cited above in not conducting the required drills at least every quarter which poses a potential safety and/or personal rights risks to persons in care.

Based on interview, the licensee did not comply with the section cited above in not submitting incident report when one of the residents was sent out to the hospital which posed a potential personal rights risk to person in care.

Based on observation, the licensee did not comply with the section cited above in the following which pose a potential health, safety and/or personal rights risks to persons in care: broken glass window; cat's feces, rusted paint pan, paint roller, piece of wood and metal on top stairs; rusted sink in area adjacent to kitchen; broken drawer knob in residents' room; pieces of metal and pieces of wood, rusted grills, soiled placemat, empty milk container on the backyard ground

Based on observation, the licensee did not comply with the section cited above in the following which pose an immediate health, safety and/or personal rights risks to persons in care: Neosporin and muscle rub in resident's room; unlocked gate leading to storage where cleaning and laundry supplies are kept; Clorox bleach in the backyard; rubbing alcohol, rust remover and hammer in unlocked basement room; unlocked peritoneal cleanser and medications

87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition.....shall not be admitted or retained in a residential care facility for the elderly: (5) Residents who depend on others to perform all activities of daily living for them......-This requirement is not met as evidenced by --Based on record review, interviews and observation, the licensee did not compy with the section above in retaining R1 who is dependent on all ADLs which poses a potential health and/or personal rights risks to person in care,

87463 Reappraisals(e) The licensee shall immediately, or as soon as reasonably possible, bring any significant change in condition....to the attention of the appropriate licensed medical professional ....-This requirement is not met as evidenced by: -Based on record review, interviews and observation, the licensee did not compy with the section above for not having R1'sLIC602A updated when R1's conditions changed which poses a potential health and/or personal rights risks to person in care.

87458 Medical Assessment: (c) The medical assessment shall include, but not be limited to: (5) The determination whether the person is ambulatory or nonambulatory as defined in Section 87101, ..The assessment shall indicate whether nonambulatory status is based upon the resident's physical condition, mental condition, or both....-This requirement is not met as evidenced by:-Based on record review and observation, the licensee did not comply with the section above in R2's LIC602A not consistent with R2's ambulatory status

87463 Reappraisals(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.-This requirement is not met as evidenced by: -Based on records review, the licensee did not comply with section above in R1 and R2's LIC602A more than a year old which pose a potential health and/or personal rights risks to persons in care.

Based on record review, the licensee did not comply with the section cited above in S4 not having LIC503 and S3's LIC503 incomplete which pose a potential health and/or personal rights risks to persons in care.

Based on record review, the licensee did not comply with the section cited above in S4, a cook, not having the required training which poses a potential health and/or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in S5 not First Aid certified which poses a potential health, safety and/or personal rights risks to persons in care.

Based on observation, the licensee did not comply with the section cited above in the following which pose an immediate health, safety and/or personal rights risk to persons in care: unlocked pocket utility knife, skin protector, razor, cleaning supplies, construction tool, pails and gallons of paint and staff medications.This is a repeat violation. A $250.00 civil penalty is assessed.

Based on observation, the licensee did not comply with the section cited above in the following which pose a potential health, safety and/or personal rights risks to persons in care: rusted dirty dining chairs and trash cans; cracked cement in between transition and heavily scratched door post in the common bathroom; broken night stand door & heavily soiled upholstered chair in resident's room; stained stairs carpet covering; shower door with mildew and water damaged lavatory with stained faucet; debris/garbage in the backyard and ramp; dusty exit door.A $250.00 civil penalty assessed for repeat violation.

Based on records review, the licensee did not comply with the section cited above in S3 and S5 not having restricted health conditions training for 2024 which pose a potential health and/or personal rights risks to persons in care.

Based on records review, the licensee did not comply with the section cited above in S3 and S5 not having the required/ complete number hours of medication training which pose a potential health and/or personal rights risks to persons in care.

Based on record review, the licensee did not comply with the section cited above in not having CPR certified staff which poses a potential health, safety and/or personal rights risks to persons in care.

Based on record review, the licensee did not comply with the section cited above in R5's two medications incorrectly recorded on LIC622 which pose potential health and/or personal rights risks to persons in care.This is a repeat violation. A $250.00 civil penalty is assessed.

Based on records review, the licensee did not comply with the section cited above in R3, R4 and R5's LIC625 missing 2 pages and R3 and R4's not signed by the residents and/or residents's responsible person which posed a potential health, and/or personal rights risks to persons in care.

Based on record review], the licensee did not comply with the section cited above in R1 not having a LIC9172 Functional Capability Assessment which poses a potential health, safety and/or personal rights risks to persons in care.

Based on record review, the licensee did not comply with the section cited above in R1 not having a pre-placement appraisal which posed a potential health, safety and/orr personal rights risks to persons in care.

Based on observation, the licensee did not comply with the section cited above in the following which poses an immediate health and/or personal rights risks to persons in care: food items in the refrigerator still in the shopping bags and box packaging materials; sausage links and Bologna in open plastic packaging material.

Based on observation, the licensee did not comply with the section cited above in the following which pose an immediate health and/or personal rights risks to persons in care: rotten mushrooms, Serrano peppers, radish, celery and carrots with mold in the refrigerator

Based on record review, the licensee did not comply with the section cited above in not having doctor's orders for R1 and R3's bed rails which pose a potential safety and/or personal rights risks to persons in care.This is a repeat violation. A $250.00 civil penalty is assessed.

87303 Maintenance and Operation(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. -This requirement is not met as evidenced by:-Based on observation, the licensee did not comply with the section above for the following which pose a potential health and/or personal rights risks to persons in care: strong smell of urine in the bathroom; mouse droppings; dusty air vents; stain and dusty floor

87506 Resident Records(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. -This requirement is not met as evidenced by:-Based on record review and interview, the licensee did not comply with the section above in not completing the record when R1's medication was received and administered which posed a potential personal rights risk to person in care.

87303 Maintenance and Operation(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.This requirement is not met as evidenced by -Based on observation, the licensee did not comply with the section above in the following which pose a potential health and/or personal rights risks to persons in care: untidy refrigerators; bathroom cabinet in disrepair; clogged lavatory; flies.This is a repeat violation within 12 month.

87355 Criminal Record Clearance(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance ............-This requirement is not met as evidenced by: -Based on observation and interviews, the licensee did not comply with the section in S1 working without fingerprint clearance which poses an immediate risk to persons in care.Civil penalty assessed.

§1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.-This requirement is not met as evidenced by -Based on interviews, the licensee did not comply with the section when staff made an inappropriatec comment toward resident which posed personal rights risk to person in care.This is a repeat violation. The first citation was issued on 3/08/24.

87307 Personal Accommodations and Services: (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, ........ -This requirement is not met as evidenced by:-Based on observation and interviews, the licensee did not comply with the section above in making the resident's room storage for staff's belongings/beds. This is a repeat violation within 12-month period. The first citation was issued 3/08/24.

87355 Criminal Record Clearance(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance ............-This requirement is not met as evidenced by: -Based on observation and interviews, the licensee did not comply with the section in S1 working without fingerprint clearance which poses an immediate risk to persons in care.Civil penalty assessed.

8730787307 Personal Accommodations and Services: (d)(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.-This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section cited above in stairway on the second floor from resident's room going to the backyard blocked with rusted lamp and commode which poses an immediate safety and/or personal rights risk to persons in care.

87202(a) Alll facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshall........-This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section cited above in converting the storage into staff bedroom which poses an immediate safety and/or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in not having doctor's order for R1, R3 and R5's bedrails which pose a potential safety and/or personal rights risk to persons in care.

Based on records review, the licensee did not comply with the section cited above in not having doctor's order which pose an immediate health, and/or personal rights risks to persons in care for the following: R`1's 10 medications; R2's 5 medications; 2 of R5's medications;

Based on record review, the licensee did not comply with the section cited above in R1,R2 & R3’s LIC602A Physician'sReports over a year old which pose a potential health and/or personal rights risks to persons in care.

Based on observation, interviews and record review, the licensee did not comply with the section cited above in R3 and R4's ambulatory status not consistent with mental/medical condition (non-ambulatory) which pose a potential health, safety and/or personal rights risks to persons in care.

Based on record review, the licensee did not comply with the section cited above in R5 not having medical assessment (LIC602A) which poses a potential health and/or personal rights risks to persons in care.

Based on record review, the licensee did not comply with the section cited above in S1's first aid certificate expired and S2, S3, S4 & S5 not having first aid certificates on file which pose a potential health, safety and/or personal rights risks to persons in care.

Based on records review, the licensee did not comply with the section cited above in staff (S2, S3, S4, S5) not having the complete required number of hours of annual training which poses potential health, safety and/or personal rights risks to persons in care.

Based on records review, interviews and observation, the licensee did not comply with the section cited above in 2 residents (R3 and R4) in bedrooms not fire cleared for non-ambulatory which poses an immediate safety and/or personal rights risks to persons in care.A $500.00 civil penalty is assessed.

87309 Storage Space: (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.-This requirement is not met as evidenced by:-Based on observation, the licensee did not comply with the section cited above in .... the following: unlocked staff medications, scissors, razors, cleaning supplies, tools cart, shovel, pails of paint, bleach, rubbing alcohol, Hydrogen Peroxide; bread toaster in one of the residents' rooms, These pose an immediate health, safety and/or personal rights risks to persons in care.

87465 Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility......by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. -This requirement is not met as evidenced by:-Based on review of records and interviews, the licensee did not comply with the section above when R1's cream run out and did not obtain nor follow-up with the doctor for the other cream.

Based on observation, the licensee did not comply with the section cited above in not having evacuation chair which poses potential safety risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in the following: unlocked staff medications, scissors, razors, cleaning supplies, tools cart, shovel, pails of paint, bleach, rubbing alcohol, Hydrogen Peroxide; bread toaster in one of the residents' rooms, These pose an immediate health, safety and/or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in stairway on the second floor from resident's room going to the backyard blocked with rusted lamp and commode which poses an immediate safety and/or personal rights risk to persons in care.

Based on observation and interview, the licensee did not comply with the section cited above in staff sleeping in the resident's room which poses a potential personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in trash cans in residents' rooms with no lids which pose a potential health and/or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in converting the storage into staff bedroom which poses an immediate safety and/or personal rights risk to persons in care.At $500.00 civil penaty is assessed.

Based on observation, the licensee did not comply with the section cited above in 2 exit doors with no auditory signals which pose an immediate health, safety and/or personal rights risk to persons in care.

§1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.-This requirement is not met as evidenced by: -Based on interviews, the licensee did not comply with the section when staff made an inappropriatec comment toward resident which posed personal rights risk to person in care.

87411 Personnel Requirements - General: (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs........-This requirement is not met as evidenced by: -Based on interviews, observation and records review, the licensee did not comply to the section above in not having sufficient staffing to be able to redirect resident timely and properly which poses potential personal rights risks to persons in care.

Based on interviews, the licensee did not comply with the section cited above in not conducting drills which poses a potential safety risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in the following which pose a potential personal rights risks to persons in care: toilet paper holder in 2 bathrooms broken; 2 bathroom doors with dilapidated paint; wood transition in bathroom flooring rotten.

Based on observation, the licensee did not comply with the section cited above in hot water at 137.8 degrees Fahrenheit.which poses an immediate health, safety and/or personal rights risk to persons in care.

87303 Maintenance and Operation(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.This requirement was not met as evidence by: Based on observation and interview the Licensee did not comply with the section cited above in having facility free of rodents, which poses a potential health and safety risk to persons in care.

87307 (3) Equipment and supplies necessary for personal care... shall be readily available to each resident... C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads... The quantity shall be sufficient to permit changing at least once per week or more often when indicated... This requirement was not met as evidence by:Based on observation the Licensee did not comply with the section cited above in have appropriate linen on bed, which poses a potential health and safety risk to persons in care.

87705 (l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors... (6)Locked exterior doors or perimeter fences.. shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents. This requirement was not met as evidence by: Based on observation the Licensee did not comply with the section cited in using a lock on entry/exit door for wander residents, which poses an immediate health and safety risk to persons in care.

87555 General Food Service Requirements (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. Based on observation the licensee did not comply with the section cited above. LPAs observed moldy cantaloupe in cabinet which poses a potential health, safety or personal rights risk to persons in care.

87468.1 Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on observation the Licensee did not comply with the section cited above. PIN 21-38-ASC states "Well-fitting face mask is required in indoor settings (double mask or surgical mask recommended), unless an N95 respirator is required pursuant to Title 8 regulations." for all staff and Licensees. However, LPAs observed Administrator Mirriam Paras, S1, S2, and S3 in facility without a mask in common areas which which poses a potential health, safety or personal rights risk to persons in care.