Magnolia Place

Record dose details and resident medication response

Based on observation and records reviewed, R2’s PRN medication Acetaminophen 650mg order on 08/20/25 was not recorded in the resident’s MAR, which poses an immediate health and safety risk for the person in care.

Based on records reviewed, S1 and S2 are not fingerprinted cleared and not associated to the facility, which poses an immediate risk to the health and safety of the residents.

Facility must keep complete hospice care plan on file

Based on record review and interview conducted, the licensee did not comply with the section cited above when LPA reviewed R1’s file who is currently receiving hospice care has no current hospice care plan on file, which poses a potential health or personal rights risk to persons in care.

Use slip-resistant surfaces in bathing areas

Based on observation, the licensee did not comply with the section cited above no non-skid mat and/or strip was observed in the residents’ shower in room 19, room 17, and room 217, which poses/posed a potential health, safety or personal rights risk to person in care.

Ensure hazardous items are locked and not unattended

Based on observation and records reviewed, R3 and R4 cannot have access to chemicals. Cleaning chemicals were observed in R3’s bathroom and under R4’s bathroom and kitchen sink unlock, which poses/posed an immediate health and safety risk for the person in care.

Early illness recognition

87411(d)(5) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (5) Knowledge necessary in order to recognize early signs of illness and the need for professional help.This requirement was not met: Based on interviews and records reviewed, staff did not seek medical attention timely for resident’s fracture with resulted from an unwitnessed fall, after R1 complained of pain, which poses an immediate health and safety and personal rights risk to the person in care.

Store centrally held medications in locked secure place

87465 (h)(2) 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.This requirement was not met as evidenced by:

Facility personnel sufficiency and competence

87411(a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs….This requirement is not met as evidenced by: Based on interviews and records review, staff did not provide care and supervision when R1 went AWOL on 11/24/24, and facility was not aware until the facility was notified by the neighbors. R2 went AWOL on 12/01/24 and the facility was not aware until the hospital called and informed the facility. R1 and R2 went AWOL poses an immediate health and safety risks to persons in care.

Record centrally stored prescriptions and refill data

87465 (h)(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year…This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above when resident’s medication and MARs was reviewed and observed medications were not logged into residents’ Centrally store medication log, which poses a potential health, safety or personal rights risk to person in care.

Limit staff assistance with self-administered drugs

87465(a)(5) Incidental Medical and Dental Care The licensee shall assist residents with self-administered medications as needed.This requirement was not met as evidenced by: Based on interviews and records review, the licensee did not ensure staff administer medications residents as prescribed by physicians, which poses an immediate health and safety risks to persons in care.

Store centrally held medications in locked secure place

Based on observation, the licensee did not comply with the section cited above when LPA and A1 observed medications inroom 130 and 103 stored unlocked accessible to residents in care this poses an immediate health, safety or personal rightsrisk 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 when LPAs and A1 observed cleaningchemicals in janitor and mechanical rooms unlocked. LPA and A1 observed chemical bottles and a knife in room 123, andchemical bottles in room 103 stored unlocked accessible to residents in care this poses an immediate health, safety orpersonal 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 when LPA and A1 observed a square hole inthe back wall under R1’s kitchen sink. Under ice machine in the kitchen LPAs and A1 observed mold, which poses apotential health, safety or personal rights risk to person in care.

Personal rights of residents in all facilities

87468.1 Personal Rights of Residents in All Facilities(a)(1) Residents in all residential care facilities for the elderly shall…be accorded dignity in their personal relationships with staff, residents, and other persons.This requirement was not met as evidenced by:

Authorized physician-prescribed self-administered meds

87465(a)(5)(A) Incidental Medical and Dental Care Facility staff…shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. Assistance with self-administered… (A) Medications…prescribed for self-administration which have been authorized by the person's physician.This requirement was not met as evidence by: Based on record reviewed and interviews conducted, the licensee did not comply with the section cited above whenstaff administered Norco to resident 1(R1). Medication was not prescribed by the resident’s physician which poses/posed an immediate health, safety, or personal rights risks to the person in care.

Facility personnel sufficiency and competence

87411(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… The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the 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 evidence by: Based on records reviewed and interviews conducted, the licensee did not comply with the section cited above whenResident 1 a non-verbal and paralyzed resident had an unwitnessed fall on 12/14/23 and was not sent to the hospital until 12/16/23 which poses/posed an immediate health, safety, or personal rights risk to persons in care.

Limit staff assistance with self-administered drugs

87465(a)(5) Incidental Medical and Dental Care The licensee shall assist residents with self-administered medications as needed.This requirement was not met as evidenced by: Based on interviews and records review, the licensee did not ensure staff administer medications to 31 residents on the evening of 01/17/23 which poses an immediate health and safety risks to persons in care.

Dignity in personal relationships

(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 LPAs observation of pictures, records review and interviews. R1's hands/arms were held while staff were attempting to assist in daily living needs. This poses an immediate risk to resident's 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 was not met as evidenced by LPA's interviews with staff and reporting party that resident was sent to hospital via EMS with only a sheet (naked) wrapped around their lower body.

Maintain cleanliness and prevent incontinence odors

(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met aas evidenced by LPAs interviews and records review that incontinence care was not provided by staff due to resident's refusal and cognitive mental state at the time. R1 was left soiled for several hours, on more than one occasion, while facility waited for assistance from R1's family.

87218 Theft and Loss(a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153 (1) The initial personal property inventory shall be completed by the licensee, and the resident, or the resident’s representative.

§1569.49 Civil penalties(c) The department shall assess an immediate civil penalty of five hundred dollars ($500) per violation and one hundred dollars ($100) for each day the violation continues after citation for any of the following serious violations:(1) Any violation that the department determines resulted in the injury or illness of a resident. This requirement was not met as evidenced by LPAs review of hospital and facility records evidencing R1 was not receiving the required blood sugar readings and or insulin injection per the physician's orders, resulting in hospitalization on two occasions. This poses a direct and immediate risk to the health and safety, or personal rights of resident's in care. A civil penalty in the amount of $500 is being assessed. This poses a direct and immediate risk to the health and safety, or personal rights of resident's in care.

Maintain facility in clean, safe, sanitary condition

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 was not met as evidenced by . During the course of a prior complaint investigation conducted it was observed that the air conditioning in room #10 was not working properly and the toilet seat in resident bathroom #1 was missing.

Facility personnel sufficiency and competence

Facility personnel shall at all times be sufficient in numbers, and competent to provide theservices necessary to meet resident needsThis requirement was not met as evidenced by staff not supervising residents in the television room,resulting in R1 assaulting R2, requiring R2 to be hospitalized for fractured ribs and pneumothoraxrequiring chest tube placement. This is an immediate risk to resident health and safety.

.The department shall assess an immediate civil penalty of five hundred dollars ($500) per violation and one hundred dollars ($100) for each day the violation continues after citation for any of the following serious violations:(1) Any violation that the department determines resulted in the injury or illness of a resident. This requirement was not met as evidenced by: LPA's observation of hospital medical records. Facility did not seek emergency medical treatment for Resident R1 on 11/20/2020, resulting in hospitalization.

Coverage for absent regular staff members

87413 Personnel - Operations (a) In each facility: (1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks. This requirement was not met as evidenced by interviews with staff and observation of police and facility reports.

(a) A resident of a residential care facility for the elderly, or the resident’s representative shall have the right to participate in decisionmaking regarding the care and services to be provided to the resident. Accordingly... the facility shall coordinate a meeting with... the resident’s representative... an appropriate member...of the facility’s staff, if the resident is receiving home health services in the facility...and a representative of the home health agency involved,. The facility shall ensure that participants in the meeting prepare a written record of the care the resident will receive in the facility...This requirement was not met as evidenced by interview with Executive Director stating a meeting with Home Health and resposible parties had not happened.

Document behavioral expression and related causes

Reappraisals(c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement was not met as evidenced by: Administrator stated he did not have a meeting with resident, resident's representative, staff and a representative from the home health

§1569.312Basic services requirementsEvery facility required to be licensed under this chapter shall provide at least the following basic services:(a) Care and supervision as defined in Section 1569.2. This requirement was not met as evidenced by: Interviews and records review stating R1's oxygen tank was empty due to a hole in the tubing. No refill was ordered or available as needed under Basic care needs. This poses an immediate health and safety risk to those in care.

Regular observation and documentation of resident changes

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: interviews with staff and reporting party. Facility was unable to provide documentation supporting that contact was made to residents responsible party Power Of Attorney (POA) received notification of the change of condition.