Glen Terra Assisted Living

87463-Reappraisals- (a)The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first,......This requirement is not met as evidenced by: Based on record review and interviews the licensee did not comply with the section cited above by not updating R1's Appraisal Needs and Services upon observing change in condition which poses a potential health, safety or personal rights risk to persons in care.

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:(2) To be accorded safe, healthful..... .This requirement is not met as evidenced by: Based on the interviews, medical record review and R1's facility file review the facility did not ensure to provide proper/enough care to R1 to prevent multiple falls which poses a potential risk to residents 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 R1's hospitalization on 03/11/2025, which poses a potential health and safety risk to persons in care.

87506 Resident Records.(e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident.This was not met as evidenced by: R1 was discharged on 10/25/18 and file for R1 was requested in April and May of 2021 but staff could not provide the file. This shows a potential health and safety risk for residents in care and supervision.

87466 Observation of the Resident..The licensee shall ensure...observed for changes in physical, mental, ...functioning .... appropriate assistance is provided...physical health condition are observed, the licensee shall ensure that such changes are documented...resident's responsible person, if any. This requirement is not met as evidenced by: Based on interviews conducted, the facility did not take any action to mitigate the falls for R1. R1 had multiple falls from September 2020 to March 2022 which resulted in serious injuries, this poses an immediate risk to residents in care.

87466 Observation of the Resident..The licensee shall ensure...observed for changes in physical, mental, ...functioning ....appropriate assistance is provided...physical health condition are observed, the licensee shall ensure that such changes are documented...resident's responsible person, if any. This requirement is not met as evidenced by: Based on interviews conducted, the facility did not take any action to mitigate the falls for R1. R1 had multiple falls from September 2020 to March 2022 which resulted in serious injuries which posed an immediate risk to residents in care.

87405 (d)(1) Administrator Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.(1) Knowledge of the requirements for providing care and supervision appropriate to the residents. Based on interviews conducted, the facility did not take any action to mitigate R1’s falls. Additionally, the facility did not contact R1’s PCP and failed to make updates to R1’s case plan which posed a potential risk to residents in care.

Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement is not being met as evidenced by: LPA observed during complaint investigation that Special Incident was not submitted for resident #1 fall and hospitalization.

Based on observation, the two double doors which house the dumpsters are unattached at the frames which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above Room 406 water temperture in bathroom sink measure 104.9 and in room #307 the sink in living room measure 103.5 which poses an immediate health, safety or personal rights risk to persons in care.

Based on observati some cans of non perisible food had expired which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, the licensse did not comply with the above. LPA and Staff observed spoiled lemons in lemon box and stale lettuce and celery which poses an immediate health, safety or personal rights risk to persons in care.

87705(I)(6) Care of Persons with Dementia. The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: Locked exterior doors or perimeter fences with locked gates shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents. This requirement was not met as evidenced by: Based on interviews & record done by LPA Tao the licensee did not ensure that locked gates do not substitute staff to meet supervision needs of residents, on 7/29/21 R1 left the facility unsupervised which poses a potential health & safety risk to residents in care.

87303 Maintenance and Operation (e)Water supplies and plumbing fixtures shall be maintained as follows: (2)(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate 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 was not met as evidenced by LPA observation, LPA inspected RM#111, #120 and #214 and hot water was measured between 122.6 to 124.7 which posed an immediate risk to the residents in care

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: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. Based on interviews, the licensee did not ensure all the residents get the covid-19 testing which poses a potential health, safety, and personal rights 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 all of the following personal rights: (2) To be accorded safe, healthful andcomfortable accommodations, furnishings and equipment.This requirement is not met as evidence by: Based on observation licensee is not ensuring receptionist is wearing a face mask at all times which poses an immediate personal rights, health, and safety risk to persons in care.*Civil Penalities for Repeat Violation were assess in the amount of $250.*

87303(a) 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 evidence by: Based on observation facility did not ensure room #219 is free of ants which poses an immediate health, safety, or personal rights riskto persons in care.

87705 Care of Persons with Dementia: (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.This requirement is not met as evidence by: Based on observation, documents reviewed facility serves dementia population, and residents may be able to open the front door and exit at any time which 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 in 3 staff observed not wearing a face covering around other staff or residents which 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 in 7 residents were having lunch in dinning room without proper 6 feet distancing which poses an immediate health, safety or personal rights risk to persons in care.