The Harvest at Fowler

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...(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidence by: Records review and interviews conducted. The licensee did not comply with the section cited above in that a report of an incident involving S1 and S2 occurring on 05/21/26 was not reported to the Department. This poses a potential health safety and or personal rights risk to residents in care.

Right to freedom from abuse and neglect

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:(8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement was not met as evience by: interviews conducted, video surveillance and records reviewed. The licensee did not comply with the section cited above in that S1 and S2 had a loud verbal altercation in the main living room of the facility with residents in the surrounding vacinity. This poses a potential health safety and or personal rights risk to residents in care.

Right to freedom from abuse and neglect

Give PRN medication by physician order

Based on review of records, the licensee did not comply with the section cited above in that 1 of 4 records reviewed disclosed medication is not being provided as prescribed. R1's MARS shows medication (Ondansetron HCL 4 mg tablet, generic for Zofran 4 mg tab with instructions take 1 tablet by mouth every 6 hrs as needed for nausea/vomitting) should have a count of 27 but has 26. Medication is short 1 tablet. This poses an immediate health, safety or personal rights risk to persons in care.

Regular observation and documentation of resident changes

87466 Observation of the ResidentThe 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. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidence by: file review. The licensee did not comply with the section cited above in that it was noted in the staff log book R2 was observed to be ill on 2/13/25 and was not taken to the physician. R2 was sent out via EMS to the hospital on 2/21/25. R2 did not receive timely medical attention for their illness. This poses a potential health safety and or personal rights risk to persons in care.

Perform a pre-admission resident appraisal

Based on record review, the licensee did not comply with the section cited above in that 2 of 3 files reviewed did not have pre-admission appraisal. Reappraisals are not being completed. Reappraisals observed to have not been completed in 2 of 3 files reviewed. (3rd file reivewed was a new resident). This poses a which poses a potential health, safety or personal rights risk to persons in care.

Ensure hazardous items are locked and not unattended

Based on LPA observation, the licensee did not comply with the section cited above in that 2 of 6 bedrooms observed with chemicals accessible to residents in care. Gardening tools observed unlocked and accessible to residents in care. This poses a potential health, safety or personal rights risk to persons in care.

Based on LPA observations, the licensee did not comply with the section cited above in that room #305 was observed with an oxygen tank inside without "oxygen in use signs posted as required. This poses a potential health, safety or personal rights risk to persons in care.

Ensure hazardous items are locked and not unattended

Based on LPA observations, the licensee did not comply with the section cited above in that various resident bathrooms and activity cabinet was observed with chemical/items that could pose a danger to residents in care unlocked and accessible. This poses a potential health, safety or personal rights risk to persons in care.

Facility must keep complete hospice care plan on file

Based on LPA interview with Administrator, the licensee did not comply with the section cited above in that R1 was admitted on hospice 5/18/24. A hospice care plan/training was not secured by the facility at time of admittance. This poses a potential health, safety or personal rights risk to persons in care.

Facility personnel sufficiency and competence

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 was not met as evidence by: LPA observation of Incident report. On 3/9/23 R1, jumped fence and AWOL'd from the facility resulting in an injury requiring medical attention.602 dated 2/17/23 stated that R1 was "not able to leave the facility unassisted". This posed an immediate health, safety and or personal rights risk to resident in care. Civil penalty assessed.

Limit staff assistance with self-administered drugs

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (5) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by Based on review of records and interviews R1 did not recieve the correct dose of medication which poses an immediate Health, Safety or personal rights risk to the clients in care.

Regular observation and documentation of resident changes

87466 Observation of the Resident 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. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidenced by Based on medical records review, R1 was admitted for cellulitis/sepsis, which poses an immediate Health, Safety or personal rights risk to the clients in care.