The Kensington at Walnut Creek

87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing... facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above in by not administering medication for R1 ordered by the physician and given according to the physician's directions. R1 was administered the same dose of narcotic medication in the morning which poses a potential health, safety or personal rights risk to persons in care.

CCR 87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. Based on record review and interviews, the licensee did not comply with section above by not administering medications to residents (i.e., R1, R2, R3, R4, R5) according to the physician's directions which poses a potential health and safety risk to the persons in care.

CCR 87465 Incidental Medical and Dental Care(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).This requirement was not met as evidenced by: Based on record review and interviews, the licensee did not comply with section above by not activating 9-1-1 if an injury or other circumstance which poses a potential health and safety risk to the persons in care.

CCR 87629(b)(1) InjectionsInjections. Ensuring that injections are administered by an appropriately skilled professional should the resident require assistance.This requirement is not met as evidence by: Based on record review and staff interviews, the licensee did not comply with the section cited above by ensuring that injections are administered by an appropriately skilled professional. Records show that Medication Technicians (Med Techs), who are not appropriately skilled professionals, were administering insulin injections and performing blood glucose checks for R2. S1 confirmed that Med Techs “set up” insulin pens and used a “hand-over-hand” method during injection. This failure to ensure proper training and delegation in medication administration poses a potential health and safety risk to residents, including risk of injury, infection, or medication error.

CCR 87465(a)(6) – Incidental Medical and Dental CareWhen requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.This requirement was not met as evidenced by: Based on record review and interviews, the licensee failed to ensure accurate medication administration documentation for R2. On 10/18/2024, the MAR reflected narcotic administration times of 6:00 a.m. and 2:00 p.m., while the Individual Resident Narcotic Record showed administration at 6:00 a.m. and 7:00 a.m. The discrepancy between the two documents demonstrates falsified or inaccurate medication administration documentation which poses a potential health and safety risk to the persons in care.

Fecal Impaction Removal, Enemas, and/or Suppositories(a) The licensee shall be permitted to accept or retain a resident who requires manual fecal impaction removal, enemas, or use of suppositories under the following circumstances: (2) Manual fecal impaction removal, enemas, and/or suppositories shall be permitted if administered according to physician's orders by either the resident or an appropriately skilled professional.This requirement was not met as evidenced by: Based on record review and interviews, the licensee did not comply with section above by not following dr's orders with R1 self-administering their intravaginal cream or appropriately skilled professional will administer the medication which poses a potential health and safety risk to the persons in care.

87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing... facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above in by not administering medication for R1 ordered by the physician and given according to the physician's directions which poses a potential health, safety or personal rights risk to persons in care.

87211 Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events... This report shall include the resident's name...This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in by not submitting a written report within 7 days of the occurences of any of the events for residents in care. Reports received to CCLD were dated 11/15/24, 11/12/24 and 12/1/24 as an example and were received on 01/02/25 which poses a potential health, safety or personal rights risk to persons in care.

§1569.683 Eviction notices (a) In addition to complying with other applicable regulations, a licensee of a residential care facility for the elderly who sends a notice of eviction to a resident...with specific facts to permit the notice to quit shall include all of the following: (3) Information about the resident's right to file a complaint...with the name, address, and telephone number of the nearest office of.. the State Ombudsman.This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above in by not sending the notice to evict with the correct contact information for the local Ombudsman to R1's responsible party which poses a potential health, safety or personal rights risk to persons in care.

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in by not reporting R1's elopement within the next day to Licensing which poses a potential health, safety or personal rights risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above in by not having prescription medication inaccessible to R1 in their apartment kitchen cabinet and refrigerator. R1's physican's report indicates "Able to administer and store own medications.." with a "No" which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in by not having PUB 475 posted in main entry (mailboxes) as a 20" x 26" poster which poses a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in by not having the CPR/First Aid updated for S2 and S6 which poses a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in by not having annual 20hrs training for S1, S2, S4, S5, S6 and S7 which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in by not having hot water temp. in residents bathrooms measuring at 105-120. The hot water temperature measured above 130 degree F which poses an immediate health, safety or personal rights risk to persons in care.

(d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury. This requirement was not met as evidence by: Based on LPAs observation and record review the Licensee did not comply with the section cited above in having S2 and S5 fingerprinted and associated to facility, which poses a potential health and safety risk to persons in care.

87705 Care of Persons with Dementia(k) The following initial and continuing requirements must be met for the licensee to utilize delayed egres devices on exterior doors or perimeter fence gates:(8) Delayed egress devices shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents and to escort residents who leave the facility. This requirement is not met as evidenced by:Based on interview, the licensee did not comply with the section cited above in by not having trained staff to meet the care and supervision needs for residents (R1) eloping from Memory Care which posed an immediate health and safety 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 is not met as evidenced by:Based on interview, the licensee did not comply with the section cited above in by not having egress doors working properly in Memory Care to prevent residents (R1) from eloping the facility which posed an immediate health and safety risk to persons in care.Repeat Violation assessed civil penalty $250.00

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above by not having current annual training for S6 and S7 which poses a potential health and safety risk to persons in care.

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above by not having current medical assessments for R5 which poses a potential health and safety risk to persons in care.

(f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident...with those activities of daily living such ...assistance with taking prescribed medications.This requirement was not met as evidenced by: Based on investigation, licensee did not comply with the section cited above by not administering medication according to doctor's orders which poses a potential health and safety risk to the persons in care.

Injections. Ensuring that injections are administered by an appropriately skilled professional should the resident require assistance. This requirement is not met as evidence by: Based on investigation, licensee did not comply with section cited above by having a staff inject insulin for R1 which poses a potential health and safety risk to the persons in care.

Based on record review, the licensee did not comply with the section cited above by not having current annual training for S6 and S7 which poses a potential health and safety risk to persons in care.

Based on record review, the licensee did not comply with the section cited above not having current medical assessments for three residents which poses a potential health and safety risk to persons in care.

Based on record review, the licensee did not comply with the section cited above by not having TB test for R4 which poses a potential health and safety risk to persons in care.

Based on record review, the licensee did not comply with the section cited above by not having health screening and TB test for S6 which poses a potential health and safety risk to persons in care.

Based on record review, the licensee did not comply with the section cited above by not completing quarterly drills which poses a potential health and safety risk to persons in care.

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1,...(4) To care, supervision, and services...competency to meet their needs.

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 evidence by:Based on observation and interview the licensee failed to secure the windows and window screens in memory care which posed an immediate Health & Safety risk to residents in care.