Carson Senior Assisted Living

Based on observation, the licensee did not comply with the section cited above. During the facility inspection, LPA identified rooms 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 203, 216, 220, and 221 that had damaged or missing window screens. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.

87466 Observation of the Resident - 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...This requirement was not met as evidenced by: Based on interviews and record review, the administrator did not take appropriate action or assistance timely medical attention for (R1) when noticeable changes were observed in (R1)’s condition. This violation poses an immediate health and safety risk to residents in care.

87631 Healing Wounds- (a)The licensee shall be permitted to accept or retain a resident who has a healing wound under the following circumstances: (1)When care is performed by or under the supervision of an appropriately skilled professional.This requirement was not met as evidenced by: Based interviews and record review, the facility did not ensure that (R1)'s pressure injuries were cared for by an appropriately skilled professional. This violation poses an immediate health and safety risk to residents in care.

87631 Healing Wounds- (a)The licensee shall be permitted to accept or retain a resident who has a healing wound under the following circumstances: (1)When care is performed by or under the supervision of an appropriately skilled professional.This requirement was not met as evidenced by: Based interviews and record review, the facility did not ensure that (R1)s pressure injuries were cared for by an appropriately skilled professional, which caused an immediate health and safety risk to (R1).

87466 Observation of the Resident - 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...This requirement was not met as evidenced by: Based on interviews and record review, the administrator did not take appropriate action or assistance timely medical attention for R1 when noticeable changes were observed in R1’s condition, which caused an immediate health and safety risk to R1.

87466 Observation of Resident -The licensee to 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. Based on LPA interviews conducted and record reviews, the Licensee was aware of of R1's history of wandering behavior failed to ensure proper supervision was in in place. This violation poses a potential health and safety risk to residents in care.

87705 Care of Persons with Dementia (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 evidence by:Based on LPA interviews conducted and record reviews, the Licensee failed to ensure to address R1's history of wandering behavior and went missing, while unsupervised by facility staff. This violation poses an immediate health and safety 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, 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 interviews and record review, (S1) failed to carry out the duties and responsiblites and left medication unattended and accessible to (R1) with dementia. This violation poses an immediate health, safety or personal rights risk to persons in care.

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 evidenced by: Based on (observation), the licensee did not comply with the section cited above. LPA identified a non-working HVAC system for room #5, #11, #165 and the main dining room.immediate This violation] which poses a potential health and safety or personal rights risk to persons in care.

87468.1 Personal Rights of Residents in All Facilities (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This requirement is not met as evidenced by: Based on (observation), the licensee did not comply with the section cited above. LPA observed non-working HVAC system for room #5, #11, #165 and the main dining room Facility failed to provide a healthful and comfortale environment. This violation which poses a potential health, safety or personal rights risk to persons in care.

(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 evidenced by: Based on [(observation), the licensee did not comply with the section cited above. LPA identified a non-working carbon monoxide, dead pest, and dangling unattached camera. This violation] which poses an immediate health, safety or personal rights risk to persons in care.

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. (1) Floor surfaces in bath...shall be maintained in clean, sanitary, and ordorless condition. (e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition....equipment shall be provided in facilities acoomodating physically handicappedand/or a non-ambulatory residents... Based on [(observation), the licensee did not comply with the section cited above. LPA identified a rusted leaky faucet, stained floor/sink, and loose toilet flusher. This violation] 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. LPA identified a non-working smoke detector missing outside the activity room in memory care. This violation] 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. LPA identified kitchen stove rear and front burners not working condition and required a match to operate. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.

87608 Postural Supports(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet.This requirement is not met as evidenced by: Based on observation and interviews, the licensee did not comply with the section cited above. The facility tied a sheet to restraint resident #1 in wheelchair. This violation poses an immediate health, safety or personal rights risk to persons in care.

87705 Care of Persons with Dementia(5) Each resident with dementia shall have an annual medical assessment...Medical Assessment, and a reappraisal done at least annually... (A) When any medical assessment, appraisal, or observation indicates... changed, corresponding changes shall be made in the care and supervision provided to that resident. This requirement is not met as evidenced by: Based on record reviews, and interviews, the facility failed to conduct an annual medical, appraisal, and needs services for resident #1 who was diagnosed with dementia. This violation poses/posed a potential health, safety, or personal rights risk to persons in care.

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department... (B) Any serious injury... occurring while the resident is under facility supervision. (D) Any incident which threatens the welfare, safety or health of any resident...This requirement is not met as evidenced by: Based on record reviews and interviews, the licensee did not comply with the section cited above. The facility failed to submit written report serveral falls and injuries of resident #1. This violation poses an immediate health, safety or personal rights risk to persons in care.

87405 Administrator - Qualifications and Duties (b) The administrator of a facility.. shall have the responsibility and authority to carry out the policies... (1) Knowledge of the requirements for providing care and supervision... (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidenced by: Based on observation record reviews, and interviews, the Administrator failed to adhere to Title 22 regulations, resulting to multiple deficiencies cited. This violation poses/posed a potential health, safety or personal rights risk to persons in care.

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes... and that appropriate assistance is provided... when such observation reveals unmet needs. When changes such as... 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... This requirement is not met as evidenced by: Based on observations, record reviews and interviews, the faciltiy failed to address resident #1 required higher level of care and supervison. This violation poses an immediate 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 and comfortable accommodations...This requirement is not met as evidenced by: Based on record reviews, and interviews, the facility failed to ensure the safety of resident #1 of falls and injuries. The faciltiy did not have a fall plan in place. This violation poses/posed a potential health, safety, or personal rights risk to persons in care.

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights... residents in privately operated residential care facilities for the elderly shall have...(8) To be free from neglect... involuntary seclusion... and verbal, mental, physical, or sexual abuse. This requirement is not met as evidenced by: Based on observations and interviews, the licensee did not comply with the section cited above. The facility confined, restricted, and isolated resident #1 in a locked room. This violation poses an immediate health, safety or personal rights risk to persons in care.

80087(a)Buildings and Grounds(a)The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.This requirement is not met as evidenced by: Based on interviews, and record review, the licensee failed to ensure that the facility was in good repair. On 6/2/22, at 10:30am, LPA and S1 observed Memory Care Dining Room ceiling missing plaster, partial open ceiling, and exposed mesh wire, which posed a potential health risk to residents in care.

Based on [(observation), the licensee did not comply with the section cited above in [1] out of [13) [(rooms) room 219] did not provide hot water. This violation poses 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 [1] out of [13] [(rooms)[identify] did not provide hot water. This violation poses 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 [1] out of [13] [(rooms) failed to produce hot water for personal care use. The violation poses immediate health, safety, or personal rights risk to persons in care.

87466 Observation of the ResidentThe licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional... appropriate assistance is provided when such observation reveals unmet needs... licensee shall ensure that such changes are documented and brought to the attention of the resident's physician... This requirement was not met as evidence by: Based on observation, interviews, and record reviews (R1) suffered head injuries during the fall. (S2-S5) observed physical changes in (R1) and failed to recognize to give immediate medical attention after a fall on 02/20/22. This violaiton poses a potential health and safety risk to residents in care.

87465 Incidental Medical and Dental Care (g) 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 including, but not limited to, an apparent life-threatening medical crisis.This requirement was not met as evidence by: Based on observation, interviews, and record reviews (R1) suffered head injuries during the fall. (R1) was not given immediate medical attention after a fall on 02/20/22. This violaiton poses an immediate health and safety risk to residents in care.

87466 Observation of the ResidentState regulations require the licensee to 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. Based on LPA observations, interviews conducted and record reviews, the Licensee was aware of of R1's history of wandering behavior failed to ensure proper supervision was in in place. This violation poses a potential health and safety risk to residents in care.

87705 Care of Persons with Dementia (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 evidence by:Based on LPA observations, interviews conducted and record reviews, the Licensee failed to ensure to address R1's history of wandering behavior and went missing, while unsupervised by facility staff. This violaiton poses an immediate health and safety risk to residents in care.

87705(c)(5)(A) Care of Persons with Dementia. Licensees... When any medical assessment, appraisal, or observation indicates that the resident’s dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident. This requirement was not met as evidenced by Based on interviews and records reviews the licensee failed to ensure that changes were made in the care and supervision when residents dementia needs have changed, R1 who was observed forgetful and confused was allowed to self administer Insulin injections which poses a potential health and safety risk to residents in care.

87303 Maintenance and Operation. The facility shall be clean, safe, sanitary, and in good repair at all times. Maintenance shall include the provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.This requirement is not met as evidenced by: LPA observed on 06/30/21 at 10:55 am on the second floor underneath the exit sign adjacent to room 280; the carpet fibers have frayed and separated which causes a safety issue. This is a violation that poses a potential Health and Safety or Personal Rights risk in residents in care.