Woodland Home

The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to (3) Any illness, injury, trauma, or change in the health care needs of the resident ... This requirement was not met when resident sustained unstageable pressure injuries while in care which posed an immediate health & safety risk to resident in care.

Additional personal rights for private residential facilities

To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse Based on R1’s medical records, Licensee did not comply with section cited above. R1 sustained a Stage 3 pressure injury on the left buttock and unstageable pressure injury on the mid-spine.

Regular observation and documentation of resident changes

The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. Based on interviews conducted, Licensee failed to comply with section above. Facility staff interviewed state they discontinued the use of alarms and mats due to safety reasons. The plan on use of mats and alarms was created by RCEB and facility staff when R1 was diagnosed with a hip fracture.

Obtain California clearance or exemption

(g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:(1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations or Based on record review, the licensee did not comply with the section cited above. The Department observed S1 did not have fingerprint clearance while working at the facility which poses an immediate health and safety risk to the clients under care.

Cash resources, personal property, and valuables of clients shall be separate and intact, and shall not be commingled with facility funds or petty cash Based on record review, Licensee did not comply with section above. On 2/16/2021, a large amount of money was missing from R1’s and other clients’ P&I money.

Give PRN medication by physician order

Once ordered by the physician the medication is given according to the physician's directions. Based on record review, Licensee did not comply with section above. There were (3) documented medication errors observed in RCEB Home Annual Review for 2020-2021 which poses an immediate threat to health and safety of clients under care

Safe, healthful, comfortable accommodations

To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.Based on investigation conducted by the Department, Licensee did not comply with the above section... ...R1 was a fall risk and required constant supervision. Facility discontinued using the fall mats and bed alarm. R1 had an unwitnessed fall on 05/27/2021 and died on 06/05/2021. Immediate cause of death is Traumatic Subdural Hematoma and condition leading to the cause of death/underlying cause is Ground Level Fall.