Jasmin Terrace at Bakersfield

Assist residents with self-administered medication

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: (4) The licensee shall assist residents with self-administered medications as needed. This requrement was not met as evidenced by: Licensee did not administer R1's prescribed aspirin that was prescibed on 1/2/26 until 1/5/26, which poses an immediate health safety and or personal rights risk to residents in care.

Grounds for eviction listed for residents

87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5) This requirement was not met as evidenced by:Licensee sent R1 to the hospital but did not allow R1 to return to the facility without following proper eviction processes which poses a potential health safety and 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 such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met by: Licensee did not ensure R1 was free from abuse by R2 hitting R1 causing injury to R1's eye resulting in medical attention for R1 which poses an immediate 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 Code section 1569.2(c). This requirement was not met as evidenced by licensee did not provide R1 care and supervision during a doctor visit on 10/10/25, which possess an immediate, health, safety, and or personal rights risk to residents in care.

Modified diets for medical necessity

87555 General Food Service Requirements (b) The following food service requirements shall apply:(7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement was not met as evidenced by: Licensee is not providing sugar free options for desert to meet the requirements of R4's specialized diet, which poses a potential health safety and or personal right risk to residents in care.

Maintain fire clearance before retaining specified persons

Based on observation, the licensee did not comply with the section cited above in having a large round dining room table blocking a fire exit, which poses an immediate health, safety or personal rights risk to persons in care.Civil Penalty was issued

Keep prescriptions in original containers

Based on [(observation) (interview) , the licensee did not comply with the section cited above in pre pouring medications for all residents in individual cups taped together in a tower with resident name scribbled (not readable) on each container, which poses/posed a potential health, safety or personal rights risk to persons in care.

Right to sufficient care and qualified staff

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. The following requirement has not been met as evidenced by: Resident 1 eloped from the facility on 06/13/2025, which poses an immediate, health, safety, or personal rights risk to residents 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. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement was not met as evidenced by R1 continues to smoke in the facility, which poses an immediate health and safety risk to residents in care.

(3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited. This requirement was not met as evidenced by: Licensee had towels with large holes in the linen closet which poses a potential health safety and or personal rights risk to residents in care.

Dignity in personal relationships

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. This requirement was not met as evidenced by Licensee did not ensure Administrator spoke to R1 appropriately and respectfully which poses an immediate health safety and or personal rights risk to residents 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 was not met as evidenced by: Licensee did not ensure R1 did not smoke inside of the facility which poses an immediate health, safety and or personal rights risk to residents in care.

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Licensee did not have staff training on how to use R5's hoyer lift, R1's oxygen equipment which poses/posed a potential health, safety or personal rights risk to persons in care.

Provide resident hot water for personal care

Based on [(observation) (interview), the licensee did not comply with the section cited above in Licensee did not have hot water turned on in R1's room and room 19 was 103.9 and room 6 104.9, which poses/posed a potential health, safety or personal rights risk to persons in care.

Clean linen quantity and hygiene supplies

Based on [(observation), the licensee did not comply with the section cited above in Licensee did not keep Room 49 bottom linen sheet clean, where a brown substance was observed and photographed (only bottom sheet was on the bed) which poses/posed a potential health, safety or personal rights risk to persons in care.

Facility maintenance and healthful environment

Based on [(observation), the licensee did not comply with the section cited above in Licensee did not maintain fence which is falling down and did not maintain fascia board around the facility is rotting (Photos taken), which poses/posed a potential health, safety or personal rights risk to persons in care.

Ensure hazardous items are locked and not unattended

Based on observation, the licensee did not comply with the section cited above in Licensee had cleaning supplies left unattended on R2's neighboring bed in room 51, which poses an immediate health, safety or personal rights risk to persons in care. Photos were taken.

Based on [(observation) (record review)], the licensee did not comply with the section cited above in Licensee did not have a diagnosis for R15 on R15's LIC602 which poses/posed a potential health, safety or personal rights risk to persons in care.

Update reappraisal at required intervals

Based on [(observation) (record review)], the licensee did not comply with the section cited above in Licensees LIC602 diagnosis for R6 did not match hospice diagnosis for R6 which poses/posed a potential health, safety or personal rights risk to persons in care.

Assist residents with self-administered medication

Based on observation and record review, the licensee did not comply with the section cited above in Licensee did not administer R7's medication by having one missed day, which poses an immediate health, safety or personal rights risk to persons in care.

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Licensee is not in substantial compliance by recieving repeated citations and not having proper documentation which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on [(observation) (interview) , the licensee did not comply with the section cited above in Licensee does not have alarms on the front door or the back doors that exit into the courtyard which poses an immediate health, safety or personal rights risk to persons in care.

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in R1 is locked in a geri chair in the dining area with no log of how often R1 is allowed out of the chair, which poses an immediate health, safety or personal rights risk to persons in care.

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Licensee does not have correct dementia training for all staff] which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Licensee did not have current care plan for R6 which stated R6 was ambulatory but needed to be turned every two hours and the care plan was expired, which poses/posed a potential health, safety or personal rights risk to persons in care.

Modified diets for medical necessity

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above Licensee does not have a modified diet plan for R6, R7, R10 or R13, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on (interview) (record review)], the licensee did not comply with the section cited above in Licensee did not hire a full time qualified employee with formal training and does not have documentation of a nutritionist, dietician or a home economist visit consultations, which poses/posed a potential health, safety or personal rights risk to persons in care.

Label and preserve medicine compliance standards

Based on observation and interview, the licensee did not comply with the section cited above in Licensee did not meet this regulation by administering CVS stomach relief, Kirkland acetaminophen and amazon allergy relief without a prescription to miscellaneous residents that request the medication, which poses an immediate health, safety or personal rights risk to persons in care. Photos of the non prescription medications were taken.

Require physician order and label for PRN medication

Based on observation interview record review, the licensee did not comply with the section cited above in Licensee did not have a written physician order on a prescription blank for R8 and R11 which poses an immediate health, safety or personal rights risk to persons in care.

Document each PRN medication dose taken

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Licensee did not document R1's PRN doses, which poses/posed a potential health, safety or personal rights risk to persons in care.

Permit PRN self-administration with written ability

Based on interview and record review, the licensee did not comply with the section cited above in Licensee did not have a physician stating R8 and R11 could communicate the need for a prescription or non prescription medication, which poses an immediate health, safety or personal rights risk to persons in care.

Based on interview, the licensee did not comply with the section cited above in Licensee is crushing and administering R9's medications camoflauging them in R9's coffee, which poses an immediate health, safety or personal rights risk to persons in care.

Limit staff assistance with self-administered drugs

Based on interview and record review, the licensee did not comply with the section cited above in Licensee is allowing S3 to administrer R7's injections, which poses an immediate health, safety or personal rights risk to persons in care. R7's LIC 602 states R7 cannot administer own medications and S3 is not a licensed professional.

Based on observation interview record review, the licensee did not comply with the section cited above in Licensee did not have a disaster plan or a plan for dementia residents, which poses an immediate health, safety or personal rights risk to persons in care.

Maintain facility in clean, safe, sanitary condition

Based on [(observation), the licensee did not comply with the section cited above in Licensee did not clean community shower, Room 17 had a dirty depends on the floor, Room 33 had urine dried on the floor, Room 67 had an unknown dried substance on the floor, Room 50 had an unknown wet substance on the floor, inside the cabinet in the tv room had mold and dead insects, which poses/posed a potential health, safety or personal rights risk to persons in care.

Keep bathing and hygiene facilities in operating condition

Based on [(observation), the licensee did not comply with the section cited above in Licensee did not have a working shower head in the TV bathroom, which poses/posed a potential health, safety or personal rights risk to persons in care.

Each terminal resident needs a written hospice care plan

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Licensee does not have care plans or current/complete plan of care for residents on hospice and R3's plan of care does not match R3's needs, which poses/posed a potential health, safety or personal rights risk to persons in care.

Report specified resident events within seven days

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 specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.This requirement is not met as evidenced by: Based on observation, interview, & record review the licensee failed to report 3 incidents to the Dept that occurred in the facility. R3 eloped from the facility and it was not reported to the Dept.

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 R3 left until R3's family arrived and was unable to locate R3 at the facility.This poses an immediate health, safety, or personal rights risk to residents in care.

Arrange appropriate medical and dental care

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:(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.This requirement is not met as evidenced by: Based on observation, interview, & record review the licensee failed to arrange or assist R4 with proper foot care.

Allowing diabetic residents based on self-management ability

Based on interview record review, the licensee did not comply with the section cited above in Licensee accepted R7 who's LIC 602 states R7 cannot administer R7's own injections or glucose testing, which poses an immediate health, safety or personal rights risk to persons in care. LPA's were unable to determine if R10 can administer own injections due to R10 not having a LIC602a.

Agree in writing on agency and facility responsibilities

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Licensee did not have an agreement in writing with home health regarding the responsibilities of R3's medical condtion, which poses/posed a potential health, safety or personal rights risk to persons in care.

Limit postural support devices to mobility needs

Based on observation interview record review the licensee did not comply with the section cited above in R1 is in a geri chair all day without a doctors note to advise purpose or use of geri chair, which poses an immediate health, safety or personal rights risk to persons in care.

Based on [(observation) (interview) (record review)], the licensee did not comply with the section in Licensee did not have training for PM Staff on 0n 06/11/24 on how to care for bedridden residents, which poses/posed a potential health, safety or personal rights risk to persons in care.

Maintain an approved first aid kit on-site

Based on [(observation) (interview)], the licensee did not comply with the section cited above in Licensee did not have a first aid kit, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on (interview) (record review)], the licensee did not comply with the section cited above in Licensee did not notify fire of bedridden residents, which poses/posed a potential health, safety or personal rights risk to persons in care.

Report specified resident events within seven days

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 specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement was not met as evidenced by Licensee did not contact R1's authorized representative to inform R1's authorized representative R1 was hospitalized which poses a potential health, safety and or personal rights risk to residents in care.

Facility must safeguard entrusted cash and valuables

87217 Safeguards for Resident Cash, Personal Property, and Valuables (b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all such articles or cash resources. This requirement was not met as evidenced by Licensee did not safegaurd R1's property which poses a potential health safety and personal rights risk to residents in care.

Call 9-1-1 for imminent health threats

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 Licensee did not call 911 when R1 fell and hit head on floor, which poses an immediate health safety and personal rights risk to residents in care.

87633 Hospice Care of Terminally Ill Residents(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility when all of the following conditions are met: (4) A written hospice care plan which specifies the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the facility is developed for each terminally ill resident or prospective resident by that resident’s hospice agency and agreed to by the licensee and the resident, or prospective resident, or the resident’s or prospective resident’s Health Care Surrogate Decision Maker, if any, prior to the initiation of hospice services in the facility for that resident, and all hospice care plans are fully implemented by the licensee and by the hospice(s). This requirement was not met as evidenced by R1 and R2 not having a Hospice Care Plan outling the responsibilities of the facility staff which poses an immediate health safety and or personal rights risk to residents in care.

(6) Identification of the training needed, which staff members need this training, and who will provide the training relating to the licensee’s responsibilities for implementation of the hospice care plan.(A) The training shall include but not be limited to typical needs of hospice patients, such as turning and incontinence care to prevent skin breakdown, hydration, and infection control. This requirement was not met as evidenced by. Licensee did not ensure staff was trained on turning R1, which poses a potential health safety and 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. This requirement was not met as evidenced by: Licensee did not keep common shower and toilets free from mold which poses a potential health safety and or personal rights risk to residents in care.

Food handling safeguards during storage and service

87555 General Food Service Requirements (b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement was not met as evidenced by: Licensee did not provide warm meals to residents recieving food tray service to their rooms which poses a potential health safety and or personal rights risk to residents in care.

Dignity in personal relationships

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. This requirement was not met as evidenced by: Licensee did not ensure S1 treated R2 and R6 with dignity and respect, which poses an immediate health safety and or personal rights risk to residents in care.

Assist residents with self-administered medication

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: (4) The licensee shall assist residents with self-administered medications as needed.This requirement was not met as evidenced by: Licensee did not administer medications on 7/31/23 for R2, R3 and R4, which poses an immediate health safety and/or personal rights risk to residents in care.

..(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who... have a hospice care plan that specifies the need for full bed rails.This requirement was not met evident by: Based on observation and record review, the Licensee did not ensure the use of full bed rails was specified in R1's hospice care plan, which poses an immediate health and safety 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. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement was not met as evidenced by: Licensee did not respond to signal system for over an hour to assist C1, which poses an immediate health safety and or personal rights risk to clients in care.

On-the-job training requirements

Based on records review and interviews, the licensee did not comply with the section cited above by staff not having any current training, which poses/posed a potential health, safety or personal rights risk to persons in care.

Maintain and operate facility under definitive plan

Based on records review and intervies, the licensee did not comply with the section cited above by not having a plan of operation at the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.

Maintain facility in clean, safe, sanitary condition

87303(a) Maintenance and Operation - The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by: Based on observation, LPA and LPM observed the ice and juice machines with mold, which poses a potential health and safety concerns to the residents in care.

Provide resident hot water for personal care

Based on observation, the licensee did not comply with the section cited above in by residents rooms measuring above 125 F and under 85F which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review and observation, the licensee did not comply with the section cited above by having residents in care that require a higher level of care, which poses/posed a potential health, safety or personal rights risk to persons in care.

Assist residents with self-administered medication

Based on observation and record review, the licensee did not comply with the section cited above by medicaitons were not administered/logged as being administered for several residents in care, which poses an immediate health, safety or personal rights risk to persons in care.

Maintain admission agreement and appraisal

Based on record review, the licensee did not comply with the section cited above by licensee not having admission agreements signed for residents, which poses/posed a potential health, safety or personal rights risk to persons in care.

Dignity in personal relationships

87468.1(a)(1) Personal Rights of Residents in All Facilities- Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on observation, LPAs observed R1 left outside calling for help, which poses a potential health and safety concern.

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 (14) Current centrally stored medications as specified in Section 87465, Incidental Medical and Dental Care Services. This requirement was not met as evidenced by Licensee was logging R1's Buspirone medication as being given, yet medication had been discontinued since 2019 which poses a potential health safety and personal rights risk to residents in care.

87465 Incidental Medical and Dental Care (b) If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication. (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement was not met as evidenced by: Licensee did not log in MARS dates and times for PRN narcotic medications were being administered to R1 which poses an immediate health safety or personal rights risks to residents in care.

87616 Exceptions for Health Conditions (a) As specified in Section 87209, Program Flexibility, the licensee may submit a written exception request if he/she agrees that the resident has a prohibited and/or restrictive health condition but believes that the intent of the law can be met through alternative means. (b) Written requests shall include, but are not limited to the following: (1) Documentation of the resident's current health condition including updated medical reports, other documentation of the current health, prognosis, and expected duration of condition. (2) The licensee's plan for ensuring that the resident's health related needs can be met by the facility. This requirement was not met as evidenced by Licensee did not have or submit a restricted/prohibited health care plan to licensing for approval for R1's prohibited health condition which poses a potential Health, Safety or personal rights risk to the residents in care.

87629 Injections (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensees who admit or retain residents who require injections shall be responsible for the following: (1) Ensuring that injections are administered by an appropriately skilled professional should the resident require assistance. This requirement was not met as evidenced by: Licensee's staff which are not skilled professionals were administering injections for R1's restricted health condition which poses an immediate health, safety and/or personal rights risk to residents in care.

Conformance with applicable laws and regulations

87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidence by:Administrator has recieved several citations under Title 22, with repeat violations which poses a potential health safety and/or personal rights risk to residents in care.

No stage 3 or 4 pressure injuries

87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement was not met as evidenced by: Licensee retrained a resident (R1) with a prohibited health condition (unstagable wound), which poses an immediate health, safety, and/or personal rights risk to residents in care.

87613 General Requirements for Restricted Health Conditions (a) Prior to admission of a resident with a restricted health condition, the licensee shall: (2) Ensure that facility staff who will participate in meeting the resident’s specialized care needs complete training provided by a licensed professional sufficient to meet those needs. (A) Training shall include hands-on instruction in both general procedures and resident-specific procedures (B)Training shall be completed prior to the staff providing services to the resident.This requirement was not met as evidenced by: Licensee did not have staff trained by a licensed professional to care for R1's restricted health condition which poses a potential Health, Safety or personal rights risk to the residents in care.

87616 Exceptions for Health Conditions (a) As specified in Section 87209, Program Flexibility, the licensee may submit a written exception request if he/she agrees that the resident has a prohibited and/or restrictive health condition but believes that the intent of the law can be met through alternative means. (b) Written requests shall include, but are not limited to, the following: (1) Documentation of the resident's current health condition including updated medical reports, other documentation of the current health, prognosis, and expected duration of condition. (2) The licensee's plan for ensuring that the resident's health related needs can be met by the facility. This requirement was not met as evidenced by Licensee did not have or submit a restricted health care plan to licensing for approval for R1's restricted health condition which poses a potential Health, Safety or personal rights risk to the residents in care.

Report specified resident events within seven days

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 specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement was not met as evidenced by Licensee did not submit incident reports for R1's hospitalization on 2/24/23, 3/18/23 and 4/18/23 which poses a potential Health, Safety or personal rights risk to the residents in care.

87608 Postural Supports (a) Based on the individual's.... the facility shall provide assistance and care for the resident in those activities of daily living...postural supports may be used under the following conditions.(2) Postural supports shall be fastened or tied in a manner that permits quick release by the resident. This requirement was not met as evidenced by:Licensee did not ensure that R1's postural support lap belt permits quick release by the resident. R1's lap belt fastenes in the back of R1's wheelchair, R1 cannot reach it.This poses a potential health, safety or personal rights risk to persons in care.

87608 Postural Supports (a) …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….limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care……. This requirement was not met as evidenced by:Licensee did not ensure that full bed rails were only used for residents receiving hospice. R1 has an order for half side rails. R1 was observed in bed will full bedrails in raised position.This poses a potential health, safety or personal rights risk to persons in care.

Fire approval and staff access to unlock systems

87705 Care of Persons with Dementia(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement was not met as evidence by LPA observation of laundry room unlock with chemicals accessible to residents with dementia. This poses a potential personal rights, health and/or safety risk to residents in care.

87555 General Food Service Requirements(9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement was not met as evidence by LPA observation of food in kitchen improperly stored in freezer (food observed with freezer burn and in incorrect freezer bags. This poses a potential personal rights, health and/or safety risk to residents in care.

87468.1 Personal Rights of Residents in All Facilities (11) To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This requirement was not met as evidence by LPA observation of a sign at the front entrance stating “visitors limited due to renovations” (renovations started 11/14/22). This poses a potential personal rights, health and/or safety risk to residents in care.

§1569.69 Employees assisting residents with self-administration of medication; training requirements.(b) Each employee who received training...and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication related issues in each succeeding 12-month period. This requirement was not met as evidenced by LPAs interview with Administrator and records review of staff training show last medication training's for current staff were in 2019. If not corrected, this poses a potential 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. This requirement was not met as evidence by LPA's observations in being that 3 of 6 rooms observed with shower not funtioning or not functioning properly. This is a potential personal rights, health or safety risk to residents in care.

Infection Control Requirements 87470(a) A licensee shall ensure that infection control practices are maintained as follows:(2)Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products. These activities shall be completed, at a minimum, as follows:(B) Walls and window coverings... shall be dusted or cleaned on a regular schedule to ensure they are safe and sanitary or when they are visibly contaminated or soiled.Walls and window coverings in resident care areas shall be dusted or cleaned on a regular schedule to ensure they are safe and sanitary or when they are visibly contaminated or soiled. This requirement is not met as evidenced by LPAs observation of facility hallway walls that were stained with feces and bodily fluids.

Maintain facility in clean, safe, sanitary condition

Maintenance and Operation 87303(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 LPAs observation of facility doors stained with dirt, fly traps hanging over dining room tables and light fixtures surrounded with cobwebs and bugs.

Facility maintenance and healthful environment

Personal Accommodations and Services(d) The following space and safety provisions shall apply to all facilities:(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement was not met as evidenced by LPAs interviews with residents and LPAs observation of the auditory alarm system that is continuously beeping loudly throughout the facility. Interviews with residents state this is causing mental distress.

Assist residents with self-administered medication

87465(a)(4)A plan for incidental medical and dental care shall be developed by each facility. .....provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.This requirement was not met as evidenced by: A sample of the medication was conducted, and files reviewed. R1 and R2 medication's were reviewed and was found that medication was missed and or not properly handled.

Keep bathing and hygiene facilities in operating condition

87303(e)(6) (e)Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition.This requirement was not met as evidenced by: Based on observation R1’s shower was not latching and staying closed.

Require physician order and label for PRN medication

87465(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, the licensee did not comply with the section cited above when staffs applied Calmoseptine ointment to blisters on R1's bottom which poses/posed a potential health, safety or personal rights risk to persons in care.

Maintain facility in clean, safe, sanitary condition

Maintenance and Operation-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. Cockroaches present in facility in resident rooms. Current Pest Control contract is insufficient to meet the facility need to control cockroaches.

Incidental Medical and Dental Care-Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. Variety of unidentified medications & vitamins observed in R1's room - not centrally stored or maintained in a locked location

Limit staff assistance with self-administered drugs

Incidental Medical and Dental Care-The licensee shall assist residents with self-administered medications as needed. MARS observed not maintained ensuring that residents are receiving assistance with rx as needed.

Ensure hazardous items are locked and not unattended

Storage Space - Disinfectants, cleaning solutions, poisons,...shall be... inaccessible to clients. Cleaning cart containing miscellaneous cleansers & bug spray observed in hallway outside of room while staff was cleaning in resident room.

87506 Resident Records (b) Each resident’s record shall contain at least the following information: (14) Current centrally stored medications as specified in Section 87465, Incidental Medical and Dental Care Services. This requirement was not met as evidenced by: Facility not keeping a centrally stored medication log for residents in care. Based on interviews and records review facility was not keeping a centrally stored log for medications of residents in care, which poses a potential health, safety or personal rights risk to persons in care.

Prohibit false or misleading facility statements

\87207 False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met as evidenced by: Based on pharmacy records review and facility records review Licensee is signing off on the MARS log indicating medication were administered, which does not reflect the amount prescribed by pharmacy records, which poses an immediate health, safety, or personal rights risk to persons in care which poses an immediate health, safety, or personal rights risk to persons in care.

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 byBased on records review and interviews, Licensee did not administer R1 and R2's medications as prescribed which poses an immediate health, safety, or personal rights risk to persons in care.

Ensure hazardous items are locked and not unattended

87309 Storage Space(a)Disinfectants, cleaning solutions...which could pose a danger if readily available to clients shall be stored where inaccessible to clientsThis requirement is not met as evidenced by: Based on observation, the licensee did not stored cleaning solutions, which poses an Immediate health, safety or personal rights risk to persons in care.