Belmar Villa

Personal rights of residents in all facilities

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:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. The following requirement has not been met as evidenced by; LPA observed Resident 2 in room with door open wearing only brief, which poses a potential, health, safety, or personal rights violation to residents in care.

Provide signal systems for large or multi-floor facilities

87303 Maintenance and Operation (i) Facilities shall have signal systems which shall meet the following criteria:(1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: The following requirement was not met as evidenced by: LPA observed signal system call button to be out of reach for several facility residents, which poses a potential, health, safety, or personal rights risk to residents in care.

Diet quality and preparation in safe healthful manner

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. The following requirement has not been met as evidenced by: LPA interviewed 4 facility residents who all stated they do not feel the facilities food service is adequate, which poses a potential, health, safety, or personal rights risk to residents in care.

Maintain facility in clean, safe, sanitary condition

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. The following requirement has not been met as evidenced by: LPA Observed lifted flooring in resident bedroom, overflowing trash bins with no lids, and dirty laundry on resident bedroom floors, which poses a potential, health, safety, or personal rights risk to residents in care.

Keep bath, laundry and kitchen floors clean

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. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement was not met as evidenced by Licensee did not keep community showers free from mold, which poses a potential health safety and or personal rights risk to residents in care.

Care and supervision as defined by statute and rules

87464 Basic Services(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Codesection 1569.2(c). Health and Safety Code section 1569.2(c) provides:(c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care.This requirement is not met as evidenced by: Based on observation, interview, and record review the licensee failed to follow physician orders by allowing the resident to elope from the facility unassisted. Facility did not know R1 left until R1's family arrived and was unable to locate R1 at the facility.This poses an immediate health, safety, or personal rights risk to residents in care.

87705: (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(4)There is an adequate number of direct care staff to support each resident’s... safety and health care needs as identified in his/her current appraisal.. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with section 87705 when the facility did not provide a 1:1 care staff to meet R1's needs as identified in R1's current appraisal, which is an potential health and safety risk to person's in care.

Prohibit tying or restricting resident hands or feet

87608 Postural Supports(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet.(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. The following requirement has not been met as evidenced by: Based on observation and records reviewed Resident 1 is not on hospice, but their bed has full bed rails, which poses an immediate, health, safety, or personal rights risk to resident in care.

Maintain facility in clean, safe, sanitary condition

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. The following requirement has not been met as evidenced by: Based on LPA observation Resident 1's room has a large pile of laundry in the corner, and smells of urine, which causes an immediate health, safety, or personal rights risk to residents in care.

Provide assistance for residents medical needs

87465(a)(2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need…This requirement was not met as evidenced by: Based on interviews and record review, this requirement was not met between 5/1/23 and 5/10/23, when home health did not conduct any wound care visits and facility and did not seek medical treatment to meet R1’s needs, which is an immediate healthy and safety risk to persons in care

Safe, healthful, comfortable accommodations

87468.1(a)(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment... This requirement was not met as evidenced by: Based on interviews, This requirement was not met when on 5/11/23, a home health nurse conducted a visit and observed R1 to be laying on a plastic covered mattress with no bedding, one sock on their feet, and the wound on their foot to be undressed.

Agree in writing on agency and facility responsibilities

87609(b)(4) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident’s medical condition(s). Based on interviews and records review, This requirement was not met when the investigation revealed that facility did not have a copy of the home health care plan and was therefore unaware of home health and facility responsibilities related to R1’s medical condition.

Ensure outdoor waste containers are cleanable

Based on observations, the licensee did not comply with the section cited above. All bedroom and bathroom waste baskets, and trash cans in hallways do not have tight-fitting lids, which poses a potential health or personal rights risk to residents in care.

Submit and maintain current mailing address

Based on observation and interviews, the licensee did not comply with the section cited above. S1 was working at the reception desk which is part of the facility and is accessible to residents in care. S1 does not have criminal record clearance. ADM advises S1 has been periodically asked to work the reception desk for a duration of 2-3 months now, which poses an immediate health, safety, or personal rights risk to residents in care.

Maintain facility in clean, safe, sanitary condition

Based on observations, the licensee did not comply with the section cited above. In room 309, the right side of window sill was observed lifted from the base with nails exposed, which poses a potential health, safety or personal rights risk to residents in care.

Protection from punishment and intimidation

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: (3)To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature...This requirement is not met as evidenced by: During the complaint inspection, LPA heard S1 yell at R1 while trying to take R1 for dinner. LPA was next door in another resident's room when LPA heard S1 yell at R1, which poses an immediate personal rights risk to residents in care.

.**This requirement is not met as evidenced by: Facility did not provide care and/or supervision to resident R1 and as a result of lack of supervision R1 went AWOL. Staff on duty were not aware that the resident R1 had left the building unassisted.***This presented an immediate or substantial threat to the physical health, mental health, or safety of the residents in care.