House of Grace 2

Based on observation, the licensee did not comply with the section cited above. Water temperature measured 127.9 - 129.5 degrees F which poses an immediate health, safety or personal rights risk to persons in care.

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 except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).This requirement was not met as evidenced by Based on interviews and records, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. The staff found the resident on the floor between on 02/28/2023 at 6:30-7am and showed signs of pain. Administrator did not contact 911 until 2:30pm.

Additional Personal Rights of Residents in Privately Operated Facilities: (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.This requirement was not met as evidenced by: Based on interviews and records, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. The facility failed to develop a care plan based on the resident’s specific needs and to address the resident as a fall risk.

Admission Agreements (e) The licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative, if any, immediately upon signing the admission agreement or modification. The licensee shall provide additional copies to the resident or resident’s representative upon request.This requirement was not met as evidenced by Based on interviews and records, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. Administrator failed to provide a copy of the admission agreement to R1's representative in a timely manner.

In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision.This requirement was not met as evidenced by Based on interviews and records, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. R1 had dementia which required that the facility had at least one night staff awake. Both S1 and S2 were asleep on 02/28/2023.