Hollywood Hills Senior Living

Give PRN medication by physician order

87465- Incidental Medical and Dental Care: c) If the resident's physician has stated in writing... 2) Once ordered by the physician the medication is given according to the physician's directions.This requirement is not met as evidenced by: Based on interviews and medication records review, licensee did not comply with the section above by not assuring that R1 and R2 prescribed medications were administered in a timely manner as prescribed. This poses an immediate health and safety risk to residents in care.

Store centrally held medications in locked secure place

Based on LPA observation, the licensee did not comply with section cited above. LPA observed the medication room open and meds refrigerator accessible, which poses an immediate health and safety risk to persons in care.

Based on LPA observation, the licensee did not comply with the section cited above as two (2) out of a total five (5) kitchen service staff were not wearing hairnets while inside the kitchen area which poses/posed a potential health, safety or personal rights risk to persons in care.

GENERAL FOOD SERVICE REQUIRMENTS- All persons engaged in food preperation and service shall observe personal hygiene and food service sanitation pratices which protect the food from contamination. This requirement is not met as evidenced by: Based on LPA observation. Two (2) out of three (3) total food services staff were found working in the facility kitchen without required gloves.

Maintain equipment and dishware in good repair

GENERAL FOOD SERVICE REQUIRMENTS-All equipment...and dishes,shall be kept clean and maintained in good repair and free of breaks, open seams, cracks and chips.This requirement is not met as evidenced by: Based on LPA observation. Kitchen dishwasher temperature guage is unreadable, and staff were unable to provide a recorded dishwasher temperature log as required in facility's dining services guidelines. This poses an potential risk to the health and safety of clients in care.

Criminal Record Clearance (e)All individuals subject to a criminal record review pursuant to …shall prior to working... in a licensed facility: (2)Obtain a California clearance or a criminal record exemption...This requirement is not met as evidenced by: Based on records review, the Administrator does not have a criminal record cleareance associated with this faciliy. Administrator has been employed with the facility since 8/10/20

Dignity in personal relationships

Personal Rights of Residents in All Facilities-(a) Residents in all residential care facilities...shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff...This requirement is not met as evdenced by: Based on interviews, facility caregiver spoke inappropriately to Resident#2 (R2), violating their personal rights, which poses a immediate Health, Safety, or Personal Rights risk to clients in care.

87464(f)(c)- "Care and supervision" means facility assumes responsibility for...assistance with activities of daily living without which the resident’s...safety, or welfare would be endangered. This requirement is not met as evidenced by: Staff interviews and record review by LPA finds R1, a resident diagnosed as having dementia, and documented instances of wandering from the faciltiy, was able to elope from the facility unsupervised. This poses a potential health and safety risk to residents in care.

Call 9-1-1 for imminent health threats

87465(g) Incidental Medical and Dental Care: Licensee shall immediately telephone 9-1-1 if an injury...has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis. This requirement is not met as evidenced by: Based on records reviewed and interviews conducted by (IB) investigator, facility staff failed to provide timely reporting of R1’s falling incident, which poses an immediate heatlh and safety risk to residents in care.

Regular observation and documentation of resident changes

(87466) Observation of the Resident-Licensee shall ensure residents are regularly observed for changes in physical... functioning...appropriate assistance is provided when such observation reveals unmet needs...This requirement is not met as evidenced by: Based on records reviewed and interviews conducted by (IB) investigator, facility staff failed to provide required medical assessment and treatment in a timely manner, which posed an immediate heatlh and safety risk to residents in care.

Training documentation requirements

Licensee shall maintain documentation pertaining to staff training in the personnel records, as specified in Section 87412(c)(2). ...Documentation shall include a notation that indicates which of the criteria of Section 87411(c)(3) is met by the trainer. This requirement is not met as evidenced by: Based on records review and interviews conducted by LPA, the facility did not provide supervisory verification that all facility "in-service" trainings were completed by S1, which poses a potential health and safety risk to residents in care.

Care of Persons with Dementia: (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... This requirement was not met, evidenced by, based on interviews and documentation, during the night shift there are inconsistencies with coverage in staffing. This poses as a potential health and safety risk to residents in care.

87506(e) - RESIDENT RECORDSOriginal records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This represents a potential health and safety issue to residents in care. This requirement is not met as evidenced by:The Licensee's Documentation Retention Policy only allows retention of documents for a minimun of 90 days and then, records are to be subsequently destroyed.

Theft and Loss (i) Reports to the local law enforcement agency within 36 hours when the administrator of the facility has reason to believe resident property with a then current value of one hundred dollars ($100) or more has been stolen…This requirement is not met as evidenced by: Based on interviews and records reviewed, the licensee did not comply with the section cited above, as the administrator did not follow the theft and loss procedures as required, which is a potential personal rights risk to residents in care.

First aid training requirements

First aid training not completed for facility staff. 87411(c)(1) Personnel Requirements-General. Staff shall receive first aid training from persons qualified by such agencies as the American Red Cross.This requirement is not met as evidenced by: Based on interviews, facility staff have not completed annual first aid training which poses a potential health and safety risk to clients in care.

Reporting Requirements. Resident authorized representatives, if any shall be sent any required reports. Licensee failed to provide an SIR regarding missed medication dose. This poses a potential health and safety risk to residents in care.

Assist residents with self-administered medication

The licensee shall assist residents with self-administered medications as needed.Based on the record review the licensee did not comply with the section cited above. LPA observed missed dose of METFORMIN on 02/18/24. This poses a potential health and safety risk to resdients in care.

Right to accept or decline care or services

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 (16) To received medical care or other services. This requirement was not met as evidenced by: Based on record review and interviews, the facility did not allow an ambulance to take R1 to the hospital immediately and receive medical care. This poses an immediate health and safety risk to residents in care.

No stage 3 or 4 pressure injuries

87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be ...retained in a residential care facility for the elderly:(1)Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by; Based on record review and interviews, the facility retained in a resident with Stage 4 and unstageable pressure injuries which poses an immediate health, safety, and personal rights risk to residents in care.

Care of Persons with Dementia:(k)The following initial and continuing requirements must be met for the licensee to utilize delayed egres devices on exterior doors or perimeter fence gates: (6) Without violating Section 87468, Personal Rights, facility staff shall ensure the continued safety of residents if they wander away from the facility. This requirement was not met, evidenced by, during interviews, R1 eloped from the memory care unit, due the elevator not being locked and secured. This is a potential health and safety risk to residents in care.

Report specified resident events within seven days

Reporting Requirements: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... This report shall include the resident's name, age, sex and date of admission; date and nature of event..This requirement was not met, evidenced by, based on interviews, facility did not submit an SIR pertaining to R1, who eloped from the memory care unit. This is a potential health and safety risk to residents in care.

87303Maintenance and Operation(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include...(5) Non-skid mats or strips shall be used in all bathtubs and showers. This requirement is not met as evidence by: During the time of the investigation LPA observed thirteen (13) random bedrooms and two (02) out of (13) were observed to have two (02) non-slip mats in the bathroom shower This may pose a potential Health and Safety risk to persons in care.

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...(b) A comfortable temperature for residents shall be maintained at all times.This requirement is not met as evidence by: During the time of the investigation staff confirmed that the heater is not working on half of the 3rd floor as of 12/12/2022. This may pose a potential Health and Safety risk to persons in care.

1569.652 Termination of admission agreement upon death of resident...(a)A residential care facility for the elderly shall not require advance notice for terminating an admission agreement upon the death of a resident...This requirement is not met as evidenced by: The Licensee did not ensure the facility issued a refund in the correct amount. R1's POA received a refund for a level of care and 2 pro rated days for the month of March. This may pose a potential Health and Safety risk to clients in care.

Personal rights of residents in all facilities

87468.1 Personal Rights of Residents in All Facilities(a)...(2) To be accorded safe, healthful... accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on observations made during the complaint investigation visit the staff did not comply with the section cited above by not wearing face mask/covering while working in the facility which poses a potential health, safety and personal rights risk to residents in care.