Twin Palms

Based on observation, interview and record review, the licensee did not comply with the section cited above in 2 out of 3 current staff members did not have current CPR/First-Aid which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, interview and record review, the licensee did not comply with the section cited above in 1 out of 4 staff members (S3) is not associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.

Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility... (1) The licensee shall arrange... for medical and dental care appropriate to the conditions and needs of residents.This requirement is not met as evidenced by: Based on interview and record reviews, licensee did not comply with the section cited above by providing care to R1 without hiring a Wound Specialist and or a medical professional from 12/26/23 to 01/09/24, which poses/posed an immediate health and safety risk to resident in care.

87405(b) Administrator - Qualifications and Duties: (b) The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee.This requirement is not met as evidenced by: Based on the investigation, the Administrator did not comply with the section cited above, failing to follow and carry out an emergency policy, which poses/posed an immediate health and safety risk to residents in care.

87411(d)(5) Personnel Requirements – General: (d) All personnel shall be given on the job training... This training and/or related experience shall provide knowledge of and skill in the following... (5) Knowledge necessary in order to recognize... the need for professional help.This requirement is not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above, as the facility staff walked away and left a hot soup on an unstable table and failed to provide an appropriate supervision. Although, the staff was trained with all the required basic services, the staff did not immediately call 911. Instead, they contacted the Administrator who made a decision to wait for R1’s doctors appointment that was already scheduled on a 05/30/23 (5 days after the incident), which poses/posed an immediate health and safety risk to residents in care.

87465(g) Incidental Medical and Dental Care. 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....This requirement is not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above, as staff did not seek medical attention for R1 in a timely manner, which poses/posed an immediate health and safety risk to residents in care.

Reappraisals: (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical...This requirement is not met as evidenced by: Based on interview and record reviews, licensee did not comply with the section cited above. Adminsitrator confirmed that upon R1's discharge from the hospital on 12/26/23, R1's reappraisal was not updated, which poses/posed a potential health and safety risk to resident in care.

Requirements: (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)...This requirement is not met as evidenced by: Based on interviews and record reviews, conducted by LPA, the licensee did not comply with the section cited above by failing to notify CCLD regarding the two (2) incidents that occured between December 2023 to January 2024, which poses a potential health and safety risk to persons in care.

87355 Criminal Record Clearance(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified...This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above. S2's first day of work was on 01/13/24 and as on 01/17/24 S2 is not associated to the facility which poses an immediate health, safety risk to persons in care.

87632 Hospice Care Waiver: (a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency... (1) Specification of the maximum number of terminally ill...This requirement is not met as evidenced by Based on record review the licensee did not comply with the section cited above by addmiting three (3) hospice residents, when theh facility is only approved for one (1). This poses/posed a potential health, safety or personal rights risk to persons in care

87211(a)(1) A,B & D Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)...This requirement is not met as evidenced by: Based on interviews and record reviews, the licensee did not comply with the section cited above by failing to notify CCLD regarding the incident that occured om 05/25/23, which posed/poses a potential health and safety risk to persons in care.

Criminal record clearance: (e) All individuals subject to a criminal record review...(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance...This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above by hiring one (1) staff member (S2) on 06/06/23 without fingerprint clearance, which poses an immediate health, safety or personal rights risk to persons in care.

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...This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above by admitting a non-hospice resident (R4) and providing a full bed rail without a doctors approval, which poses an immediate health, safety or personal rights risk to persons in care.

87705(f)(2) Care of Persons with DementiaOver-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.This requirement is not met as evidenced by: Based on observation, staff did not ensure that cleaning chemicals were inaccessible to residents in care which poses an immediate hazard to the health, safe and personal rights to the residents in care.