Incident investigation·June 18, 2024

Citations

34 citations recorded^*CCLD

• 87465(a)(8)Type B

  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.

• 87211(a)(1)Type B

  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.

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• 87464(f)(1)Type A

  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.

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• 87465(a)(1)Type B

  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.

• 1569.695(a)Type A

  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.

• 87303(a)Type B

  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.

• 87303(e)(2)Type B

  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.

• 87303(e)(6)Type B

  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.

• 87307(a)(3)(C)Type B

  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.

• 87307(d)(2)Type B

  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.

• 87309(a)Type A

  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.

• 87458(b)(1)Type B

  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.

• 87463(a)Type B

  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.

• 87465(a)(4)Type A

  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.

• 87465(a)(5)Type A

  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.

• 87465(a)(5)(D)Type A

  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.

• 87465(b)Type A

  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.

• 87465(c)(3)Type B

  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.

• 87465(e)Type A

  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.

• 87465(h)(4)Type A

  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.

• 87555(b)(17)Type B

  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.

• 87555(b)(7)Type B

  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.

• 87606(b)Type B

  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.

• 87606(f)(3)Type B

  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.

• 87608(a)(1)Type A

  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.

• 87609(b)(4)Type B

  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.

• 87628(a)Type A

  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.

• 87633(a)(4)Type B

  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.

• 87633(b)(6)Type B

  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.

• 87633(d)Type B

  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.

• 87705(c)(3)Type B

  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.

• 87705(c)(4)Type A

  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.

• 87705(j)Type A

  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.

• 87633(a)(2)Type B

  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.