The Burlington

Based on interview conducted, observation, and records reviewed, LPA, A1 and S1 observed R3’s medication Spiriva Respimat inhaler filled on 09/24/25 and medication Levocetirizine filled on 10/09/25 not record in Centrally Stored Medication (Lic 622) record, poses/posed a potential health and safety and personal rights risk to the resident in care.

Based on observation and records reviewed, R2 was observed laying in hospital bed with half rails up. There is no doctor’s order for half rail bed for R2, which poses/posed a potential health and safety and personal rights risk to the resident in care.

Based on observation, records reviewed, and interview conducted, R1 is on hospice care was observed laying in bed using a hospital bed with full rail with doctor’s order for half rail bed, which poses/posed a potential health and safety and personal rights risk to the resident in care.

87608(a)(5)(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 is not met as evidenced by: Based on interviews conducted, observation and records reviewed, R1 is not on hospice care was observed lying bed using a hospital bed with full rail with no doctor’s order, which poses/posed a potential health and safety and personal rights risk to the resident in care.

87468.2 (a)(8) 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 is not met as evidenced by: Based on interviews conducted, S1 and R1 had a verbal altercation after R1 continuously squirt S1 with a water gun which poses an immediate health and safety risks to persons in care.

Based on observation, the licensee did not comply with the section cited above when LPA and Licensee observed at approximately 1:35PM, a shovel placed against the facility wall outside room 6 patio. At approximately 1:48PM, LPA and L1 observed a tool set and automatic screwdriver stored in between the kitchen counter unlock accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above when LPA and L1 observed at approximately 1:50PM, a hole in the wall under kitchen sink, which poses a potential health, safety or personal rights risk to person in care.

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: Based on interviews conducted, it was confirmed, S1 called R1 inappropriate names and did not speak to residents at the facility in an appropriate manner when approaching residents which poses an immediately health and safety and personal rights risk to the person in care.