Glen Park at Glendale - Boynton St

(a)...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 was not met as evidenced by: Based on interviews conducted and video reviewed by LPA, R1 was handled in a rough manner by S1 which posed an immediate health and safety or personal rights risk to clients in care.

Personnel Requirements: All personnel shall be given on the job training or have related experience with knowledge required to safely assist with prescribed medications. This requirement was not met as evidenced by: on or around 09/26/25, R1 was packed R2's medication in error, for R1's outing. This posed a potential health and safety risk to the resident in care.

80061(b) Reporting Requirements. Upon the occurrence…a report shall be made to the licensing agency..., a written report ...within seven days following the occurrence of such event.This requirement was not met as evidence by Based on file document review, the Licensee did not comply with the section cited above. Administrator didn't submit a SIR for R2 regarding his/her injuries on 07/10/25. This poses a potential health and safety risk to residents in care.

§1569.269 Enumerated rights; severability(a) Residents of residential care facilities for the elderly shall have all of the following rights:(6) To care, supervision, and services that meet their individual needs... This requirement is not met by: Based on the LPA's record review and staff Interviews the licensee/administrator failed to ensure the care, supervision and services of resident #1 (R1) while in the facility. This posed an immediate health and safety risk to residents in care.

§1569.73 Terminally ill residents... (b) At any time that… the facility... determines that the resident's condition has changed ... the facility may initiate procedures for a transfer.This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above by retaining Resident #1 (R1) with a worsening prohibited health condition and not applying for an exception which posed a potential Health, Safety, or Personal Rights risk to persons in care.

Personal Rights...(19) To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies.This requirement is not met as evidenced by: Based on record review and interview the licensee did not provide the records of R1 and R2 to the authorized representative in a timely manner which poses a potential personal rights risk to the residents in care.

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, residents in privately operated residential care facilities for the elderly shall have all of the following..(8)..free from ...physical...abuse This requirement is not met as evidenced by;Based on interviews and record review, the facility did not ensure that the residents was free from physical abuse which poses an immediate health, safety and personal rights risk to residents in care.

87468.1 Personal Rights of Residents in All Facilities; (a) Residents in all residential care facilities for the elderly shall have the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by;Based on interviews and record review, the facility did not ensure that the residents treat each other with dignity and respect which poses an immediate health, safety and personal rights risk to residents in care.

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by; Based on interviews, the facility was without a fully functional phone for two to five days which poses a potential health, safety and personal rights risk to residents in care.

87705 Care of Persons with Dementia(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication,..and toxic substances such... cleaning supplies and disinfectants. This requirement was not met as evidence by: Based observation, staff do not ensure that cleaning supplies were locked and inaccessible to clients, this poses an immediate health and safety and personal rights risk to persons in care.

87705 Care of Persons with Dementia (b) (2) ...the plan of operation shall address the needs of residents with dementia, including: Safety measures to address behaviors such as wandering, aggressive behavior...This requirement is not met as evidence by; Facility staff did not ensure that the needs of dementia residents were properly addressed. Based on interviews and observations facility staff failed to ensure R1 was supervised by staff which poses an immediate health, safety and hazard to residents in care.

87465-Incidental Medical & Dental Care (c) If the resident 's physician stated in writing that the resident is able to determine his/her own precription medications...the licensee shall be permitted to assist resident with self administration...(2) Once ordered by the physcian the medication is given the physcian the medication is given according to the physician's directions.This requirement was not met as evidenced by...The facility staff mixed up the medication of R1 and R2. Each were given the wrong medication. This poses an immediate and health and safety risk to residents in care.

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement was not met as evidenced by: Staff interviewed stated that resident #1 required one to one supervision, or a higher level of care. Resident #1 was not provided with sufficient supervision which resulted in resident #1 sustaining multiple 1st and 2nd degree burns.

(b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. This requirement was not met as evidenced by: Staff interviewed stated that resident #1 had severe cognitive impairment and a history of wandering. The facility did not provide safety measures to address resident #1's wandering behavior, which resulted in resident #1 sustaining multiple 1st and 2nd degree burns.

87705 Care of Persons with Dementia (b) (2) ...the plan of operation shall address the needs of residents with dementia, including: Safety measures to address behaviors such as wandering, aggressive behavior...This requirement is not met as evidence by; The Licensee did not ensure that the needs of dementia residents were properly addressed. Based on interviews, the licensee failed to ensure R1 was supervised by staff which poses an immediate health, safety and hazard.

Based on observation, the licensee did not comply with the section cited above. Labels on PRN medications are missing which poses/posed a potential health, safety or personal rights risk to persons in care.

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: Resident #1 suffered first and second degree burns to face and body, from being scalded by hot water in bathtub. Record review and interviews indicated that resident #1 needed close monitoring due to severe cognitive impairment and wandering behavior. Lack of supervision resulted in resident #1 suffering first and second degree burns.

Resident Records. Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement was not met as evidenced by: Facility administrator was unable to locate resident #1's file during today's visit.

Additional Personal Rights of Residents in Privately Operated Facilities...All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers... This requirement is not met as evidenced by:Based on observations, interviews and file review the licensee did not comply with the section cited above bynot ensuring R1 has a 1:1 from 7am- 11 pm. This resulted in R1 sustaing an unwitness fall at 11:35 am, which poses an immediate health, safety, or Personal rights risk to persons in care.

87468.1 Personal Rights for all Residents:(a)Residents... shall have all...personal rights: To have their visitors, ... permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed uponThis requirement is not met as evidency by: Based on document review and interviews conducted licensee did not provided visitation at all times for residents in care which poses a health, safety, or personal rights risk for the persons in care.

87303 Maintenance and Operation (e)(2)(2) Faucets used by residents for personal care ..... the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). The requirement is not met as evidenced by: based on LPAs observation, LPA observed the hot water temperature was measured at Rm#8, #16, #47, #49, #53, #55 and #55 are beyond the required 105-120 degrees F which poses an immediate Health and Safety risk to residents in care.