Woodland Hills Retirement Home

Based on observation, the licensee did not comply with the section cited above as hot water in three (3) out of three (3) bathrooms measured outside of the required range of 105-120 degrees F which poses an immediate health, safety or personal rights risk to persons in care.

87355(e)(1) Criminal Record Clearance. Prior to working, residing or volunteering in a licensed facility, all individuals subject to a criminal record review shall obtain a clearance or criminal record exemptionThis requirement is not met as evidenced by: Based on observation, record review, and interview, Staff #1 did not have a criminal record clearance which poses an immediate health, safety, or personal rights 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:This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above as two employees were observed without a criminal record clearance which poses an immediate health, safety, or personal rights risk to persons in care.

87465 Incidental Medical and Dental Care (d)If the resident is unable to determine his/her own need for a...PRN medication...facility staff...shall be permitted to assist the resident...provided all of the following requirements are met:This requirement is not met as evidenced by: Based on medication review, the licensee did not comply with the section cited above as PRN medications for 3 residents were not properly logged which poses a potential health, safety, or personal rights risk to persons in care.

87465 Incidental Medical and Dental Care (h)The following requirements shall apply to medications...: (5)Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above as medications were stored in pill boxes three days in advance which poses an immediate health, safety, or personal rights risk to persons in care.

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored:(4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws...This requirement is not met as evidenced by: Based on interviews and medication and record reviews, the licensee did not comply with the section cited above as 3 medications were not properly maintained which poses an immediate health, safety, and personal rights risk to residents in care.

Based on observation, interview, and audit, the licensee did not comply with the section cited above in three (3) out of medications packets/bottles were incorrectly documented in the LIC622 and 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 one out of out of one emregncy procedures were not available and posted, which poses/posed 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 in one out of one evacuation plan sketch was not posted, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above as 7 out of 7 staff member did not have Dementia training which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in 5 out of 6 residents did not have their initial Needs and Service plan signed and 1 resident did not have a re-appraisal based on change in condition which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above as 7 out of 7 staff did not have the initial and annual training which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above as 6 out of 6 residents did not have their PRN Authorization Letter which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above as 3 out of 5 residents did not have bed rail orders which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above as the LPA did not observed the required quartely emergency training which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above as 1 out of 6 residents did not have Tuberculosis which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above as 6 out of 7 staff members did not have their Tuberculosis test or immunizations which poses/posed a potential health, safety or personal rights risk to persons in care.

87465(a)(4) Incidental Medical and Dental. The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on observation, the licensee did not comply in the section cited above for two out of three residents (R1, R2) which poses an immediate health and safety risk to residents in care. The Administrator agreed to the following:

87465(h)(6) Incidental Medical and Dental Care: The following requirements shall apply to medications which are centrally stored: The licensee shall be responsible for assuring that a record of centrally stored presciption medications...is maintained… This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above, as two (2) out of three (3) resident files did not contain properly completed centrally stored medication logs, which poses a potential health, and safety risk to persons in care.

87307(a)(B) Personal Accommodations and Services Living accommodations... shall ... provide...privacy for the residents, staff...(B) No room commonly used for other purposes shall be used as a sleeping room...This requirement is not met as evidenced by: Based on observation, the licensee failed to ensure that common areas were used appropriately, as staff confirmed sleeping on the couch, which poses a potential health and safety risk to residents in care.

Based on observation, the licensee did not comply with the section cited above as 2 out 3 restrooms measured water temperatures above 120 degrees Fahrenheit, which poses an immediate health and safety risk to persons in care.

Based on observation, the licensee did not comply with the section cited above as the water heater door in the backyard was in disrepair and the kitchen diswasher was inoperable, which poses a potential health and safety risk to persons in care.

Based on observation, the licensee did not comply with the section cited above as cleaning supplies were accessible under the kitchen sink and unlcoked garage, which poses an immediate health and safety risk to persons in care.

Based on observation, the licensee did not comply with the section cited above as in 1 staff at the facility is still pending clearance, which poses an immediate health and safety risk to persons in care.

Based on observation, the licensee did not comply with the section cited above as the LPA observed unlocked and accesible medications in multiple kitchen cabinets, which poses an immediate health and safety risk to persons in care.

Based on observation, the licensee did not comply with the section cited above as there were various expired pershiable items found which poses a potential health and safety risk to persons in care.

87632 Hospice Care Waiver(d) If the Department grants a hospice care waiver it shall stipulate terms and conditions of the waiver as necessary to ensure the well-being of terminally ill residents and of all other facility residents, which shall include, but not be limited to, the following requirements: (2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of

87633 Hospice Care of Terminally Ill Residents(h) For each terminally ill resident receiving hospice services in the facility, the licensee shall maintain the following in the resident’s record: (4) A copy of the resident’s current hospice care plan approved by the licensee, the hospice agency, and the resident, or the resident’s Health Care Surrogate Decision Maker if the resident is incapacitated.This requirement was not met as evidenced by: Licensee had no records regarding R1's hospice care, including no hospice care plan or hospice care provider visits, which posed a potenital health and safety risk to residents.

87463 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, mental, and social condition. This requirement was not met as evidenced by: After R1's two inpatient hospitalizations in which hospice was advised due to R1's declining health, licensee failed to complete a reappraisal of R1's condition, which posed a potential health and safety risk to residents.

87211 Reporting Requirements(a) 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. (D) Any incident which threatens the welfare, safety or health of any resident, such as

Based on [(observation), the licensee did not comply with the section cited above in which poses/posed 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 in 3 out of 5 rooms 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 2 out of 5 rooms which poses an immediate health, safety or personal rights risk to persons in care.