Pathway Assisted Living/ Westchester Gardens

87555 General Food Service Requirements(b) The following food service requirements shall apply: (21)Freezers of adequate size shall be maintained at a temperature of 0 degrees F (-17.7 degrees C), and refrigerators of adequate size shall maintain a maximum temperature of 40 degrees F (4 degrees C). They shall be kept clean and food stored to enable adequate air circulation to maintain the above temperatures. This requirement was not met as evidenced by LPAs observation and pictures received showing refridgerator thermometer temperature read at 53 degrees.

Onsite food stock levels for nonperishables and perishables

Based on observation, the licensee did not comply with the section cited above in the kitchen, refrigerator, freezer, and food storage, there is not enough food on hand for residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in all staff counts which poses/posed a potential health, safety or personal rights risk to persons in care.

Agree in writing on agency and facility responsibilities

Based on record review, the licensee did not comply with the section cited above in two out of the seven files which poses/posed a potential health, safety or personal rights risk to persons in care.

Facility must keep complete hospice care plan on file

Based on record review, the licensee did not comply with the section cited above in 2 out of 2 client files which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in two out of two files which poses/posed a potential health, safety or personal rights risk to persons 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 administered 1 ml of morphine instead of the prescribed dose of .25 ml on 5/2/25 8 PM to 5/5/25 8 AM, which poses an immediate health safety and or personal rights risk to residents in care.

(h) The following requirements shall apply to medications which are centrally stored:(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 and includes: (C) The drug name, strength and quantity. This requirement was not met as evidenced by LIcensee logged in the wrong strength of morphine for R1. Licensee received 1 ML of morphine and logged on the centrally stored log .25 ml was received for R1, which poses a potential health safety and or personal rights risk to residents in care.

Mark taps at high-temperature threshold

Based on observation, the licensee did not comply with the section cited above in facility which poses an immediate health, safety or personal rights risk to persons in care.

Separate storage for cleaning chemicals

Based on observation], the licensee did not comply with the section cited above in the hall closet it was observed food stored with disposed bio-hazard material which poses an immediate health, safety or personal rights risk to persons in care.

Dignity in personal relationships

Amended 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 when S1 called R1 “Old man” and made statements to R1 “You’re my big baby” and You’re my love”. This poses an immediate health, safety and/or personal rights risk to residents in care.

HSC 1569.58(a)(2) Conduct Inimical- (2) Engaged in conduct which is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility, or the people of the State of California.This requirement was not met as evidenced by: ***This requirement was not met when S2 instructed S1 to lie to licensing about an allegation of inappropriate touching of a resident. This poses an immediate health, safety and/or personal rights risk to residents in care.

Prohibit false or misleading facility statements

87207. 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: ***This requirement was not met when S1 made a false statement to the Department regarding a report of inappropriate touching of a resident. This poses an immediate 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 when S1 flicked the genitals of R1 and S1 and S2 laughed about it. This poses an immediate health, safety and/or personal rights risk to residents in care.

87608 Postural Supports(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. This requirement was not met as evidenced by LPAs observation of Resident R1's bed with full bed rails. LPA reviewed discharge paperwork from SNF dated 08/14/23, stating R1's ambulatory status is "total" care. R1 is not receiving Hospice Care Services. This poses a potential risk to the health, safety or personal rights to persons 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. This requirement was not met as evidenced by LPA's observation of Resident R1, records review and interviews with staff. Facility has not completed training with a licensed professional for incontinence care. Facility currently has 8 out of 27 residents with incontinence. This poses a potential risk to the health, safety or personal rights to persons in care.

87611 General Requirements for Allowable Health Conditions (b) The licensee shall complete and maintain a current, written record of care for each resident that includes, but is not limited to, the following:This requirement is not met as evidenced by: R1 returned to the facility from the hospital last week with a new order for use of oxygen gas administration and the facility did not create a written care plan for R1, 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.This requirement is not met as evidenced by: LPA observed cockroach nymphs scatter after pulling away plastic crate stored under commercial stainless kitchen sink and observed cockroach droppings covering entire floor where crate was stored. This poses a potential health or personal rights risk to residents in care.

87618 Oxygen Administration - Gas and Liquid (a) ...the licensee shall be permitted to accept or retain a resident who requires the use of oxygen gas administration under the following circumstances: (2) If intermittent oxygen administration is performed by an appropriately skilled professional.This requirement is not met as evidenced by: When R1 was discharged from the hospital last week with orders for oxygen administration, S1 and S2 assisted R1 with oxygen administration even though S1 and S2 were not appropriately skilled professionals, and were not given any specific instructions for how to care for R1 with the use of oxygen gas administration. This poses an immediate health, safety, or personal rights risk to residents in care.

Health screening and fitness requirements

87411 Personnel Requirements – General (f) All personnel,..., shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment...This requirement is not met as evidenced by: During the inspection for complaint #24-AS-20230622113235, LPA found that R1 and R3 do not have health screening records. R3 does not have TB results. R1 has been working since 4/26/23 and R3 has been working since 6/8/23. This poses a potential health, safety, 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' … personal property and valuables which have been entrusted to the licensee or facility staff…This requirement is not met as evidenced by: S1, S2, and MAN stated resident's laundry are collected and laundered together, and may not always know which resident the clothing belongs to. R4 stated R4's clothing have gone missing after being laundered and have not been given back. R4 advised R4 inquired missing clothing to staff but staff did not know and told R4 they had not seen it. S1, S2, and MAN stated staff will and have used disposable underwear from another resident's supply if the resident being changed has run out of their own disposable underwear supply. This poses a potential health or personal rights risk to residents in care.

Staff training in personal care activities

87411 Personnel Requirements – General(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69:This requirement is not met as evidenced by: During the inspection for complaint #24-AS-20230622113235, LPA found that R2 and R3 do not have proof of initial training. R2 has been working in the facility since 5/19/23 and R3 has been working since 6/8/23. This poses a potential health, safety, or personal rights risk to residents in care.