Springville

Based on observation, the licensee did not comply with the section cited above. At the time of inspection, LPAs observed medication in rooms #122 and #125 , on a bedside table and in a cabinet, 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. Prescribed medication (Nystatin cream), was observed without a prescription label, original box with prescription label was disposed of, 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 observed that facility does not have "No smoking oxygen in use" signs posted on the residents’ rooms who are in hospice and use oxygen, 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. At the time of inspection, LPA observed medication in the room #202, on bedside table 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 observed that there's not enough food supply for 7 days non-perishable, which poses/posed a potential health, safety or personal rights risk to persons in care.

87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is requiredThe requirement was not met as evidenced by LPA's interviews, the administrator admitted the facility was lack of staffing and they did not have any isolation room during that period of time and R1 was still having COVID symptoms which posed a potential risk 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(11)To have their visitors... permitted to visit privately...This requirement was not met as evidenced by: Based on observation and interview, the administrator failed to allow residents their private visits at any given time by requiring them to schedule visits and visits to not be in their rooms if preferred, 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:(6)...to not be locked into any room, building, or on facility premises by day or night.This requirement was not met as evidenced by: Based on observation and interview, the administrator admitted to tying a stanchion red rope accross resident room doors to enforce isolation requirements put forth by the facility, which poses a potential Health, Safety, or Personal Rights risk to persons in care.

87405 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. The requirement was not met as evidenced by Department review of medical records was completed which revealed systemic failures at the facility in preventing pressure injuries which posed a potential risk to residents in risk

87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities shall...:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This requirement is not met as evidence by: Based on document review, and interviews licensee did not ensure to seek medical care in a timely manner for R1 which poses an immediate risk to the health, safety, or personal rights to the persons in care.

87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...assistance and care as...This requirement is not met as evidence by: Based on document review and interviews conducted licensee did not ensure staff provided a two person assist for R1 which poses an immedicate risk to the health, safety, or personal rights to the persons in care.

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities(a)(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)(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. The requirement was not met as evidenced by record review, when R1 was admitted to facility and facility staff was aware of R1 had a red mark on buttock area and facility did not update and develop a plan of care which posed a potential risk to residents in care.

87466 Observation of the ResidentThe 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. When changes such as unusual weight gains or losses or 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 and the resident's responsible person, if any. The requirement was not met as evidenced by LPA's interviews and R1's family reported they never got any updated from facility about the resident's change of condition until the day the family took R1 out from facility.

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 admitted or retained in a residential care facility for the elderly:(1) Stage 3 and 4 pressure injuries. The requirement was not met as evidenced by record review, R1 had a total of 4 pressure injuries and determined to be stage 3 and R1 was still retained in the facility which posed an immediate risk to residents in care.

Based on record review, LPA observed all the staff do not have first aid and CPR in file except Administrator which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, LPA observed Resident#1 and #2 admission agreemnt was printed less than 12 point type size and on double side of the paper which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on the record review, LPA did not observe staff has any training on emergency and disaster which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, LPA observed the facility does not have any documentation about facility conduct a drll at least quarterly for each shift which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on the observation, LPA inspected the Resident room#206 and #101 and their water temperature were tested between 100.2 and 100.7 degrees F which is under Title 22 regulation and posed an immediate risk to residents in care.

Based on the record review, LPA did not observe any training record for staff in file which poses/posed a potential health, safety or personal rights risk to persons in care.

87705Care of Persons with Dementia(f) The following shall be stored inaccessible to residents with dementia:(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). During tour, LPA observed storage door 3 to be unlocked and contained various tools, paint, oxygen tank and other potiential dangerous tools.

Licensing 87506Resident Records(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. (13) Continuing record of any illness, injury, or medical or dental care, when it impacts the resident's ability to function or needed services.(c) All information and records obtained from or regarding residents shall be confidential.This requirement is not met as evidenced by: At 2:29 pm LPA observed "Blood Glucose Testing and Insulin Injection Sheet" taped to the outside of R3 bedroom door and "Incontinence Log" taped to the outside of R4 bedroom door. LPA observed these logs on several residents doors throughout the facility.

87465 Incidental Medical and Dental Care(h) The following requirements shall apply to medications which are centrally stored:(1) Medications shall be centrally stored under the following circumstances:(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.This requirement is not met as evidenced by: LPA observed 2 bottles of medication for R1 and R2 sitting on top of a water dispenser machine, in dinning area. Medications were accessible to 35 out of 35 residents in care.

(e) Water supplies and plumbing fixtures shall be maintained as follows: (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 degrees C) and not more than 120 degree F (49 degrees C).This requirement is not met as evidenced by: 1st Floor shared bathroom# 1 and #2 water temperature read at 98.6 degrees F in bathroom # and 96.4 degrees F in bathroom#1.

Based on observation the licensee did not comply with the section cited above. The water temperature was tested in a random selection of resident bathrooms. Hot water temperature measured at 122.2 degree F in bathroom #201 and in share bathroom for the rooms #202 and # 203 which is beyond the required 105 - 120 degrees 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. Cleaning supplies and toxins were observed in the laundry room unlocked and accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above. During the visit LPA observed that staff Staff 1 (S1) was not have a criminal record clearance which poses an immediate health, safety or personal rights risk to persons in care.

Based on medication review, LPA observed Administrator did not have current, up to date, centrally stored prescription medication records for the residents in care. Facility uses Medication Administration Record Sheets (MARS) to log medications, however the records were not accurate and up to date for each resident. This poses a potential health, safety, and/or personal rights risk to the residents in care.