Savant of Burbank East

87463-Reappraisals- (a)The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first,......This requirement is not met as evidenced by: Based on record review and interviews the licensee did not comply with the section cited above by not updating R2's Appraisal Needs and Services upon observing change in condition 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...(1) To be accorded dignity in their personal relationships with staff, ....This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above by permitting Staff #1 (S1) to be disrespectful towards residents, which posed 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: (2) To be accorded safe, healthful and comfortable...... This requirement is not met as evidenced by: Based on the observation and interviewsthe Licensee did not comply with the section cited byexposing other residents to uncomfortable environment which was caused by R1's screaming/yelling which posed a potential Health, Safety, or Personal Rights risk to persons in care.

87464(f)(1) Basic Services. Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on IB interviews and R1’s records review, the licensee-administrator failed to ensure that R1 was properly supervised which resulted in R1 sustaining serious injuries from multiple falls which posed an immediate health and safety and personal rights risk to resident in care.

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not met as evidenced by: Based on LPA interview and record review, staff violated R1 personal rights of cutting their hair w/o family permission, which poses an immediate health & safety and personal rights risk to the residents in care.

To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This requirement is not met as evidenced by: Licensee did not ensure that the roof top was locked and inacessible to resident resulting to resident jumping off the rooftop of the building resulting to hospitalization and eventual death. This poses an immediate health, safety and personal rights risk to the residents in care.

(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: Resident #1's needs were not met as evidenced by staff interviewed stated that resident #1 was not changed as needed due to the facility not having sufficient staff at the time of the incident.

(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. This requirement was not met as evidenced by: Resident #1 was admitted to hospital on 7/18/21 with a stage 3 sacral ulcer, and an unstageable right low back pressure injury.

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. 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. This requirement is not being met as evidenced by: Interviews conducted with facility staff and investigatory leads revealed that R1 was not sent out to the hospital when observed by facility staff not at his normal baseline or a change in condition. Interviews conducted were consistent in stating that R1 was not at his normal baseline for days and or up to three weeks, at which and during this time R1 sustained unwitnessed falls and required higher level of care. R1’s change in medical condition was communicated with his POA/Sister and at the request of the POA, facility staff did not transport R1 to the hospital for further evaluation. Facility staff did not ensure that any changes in R1’s medical and physical condition were documented and brought to the attention of R1’s Primary Care Physician. On 1/3/21, R1 was found unresponsive by facility staff, requiring hospitalization. This poses an immediate health, safety or personal rights risk to persons in care.

Incidental Medical and Dental Care.The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service. This requirement is not being met as evidenced by:R1 had an appointment scheduled with an Optometrist sometime in October or November of 2021 (exact date unknown) and R1 ended up missing her appointment due to facility not providing transportation and failing to make arrangements for R1 to see her Optometrist. LPA discovered that there was no driver on the day of the appointment.

Reappraisals. 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 is not being met as evidenced by:While reviewing the file for R1, LPA discovered that R1 had concerns related to her vision (Right Eye), prior to her admission at BRVE. On the summary report from Emerald Terrace Convalescent Hospital (ETCH), dated 6/26/202, it states “follow up with Ophthalmology due to Right Eye blindness”. While reviewing the Preplacement Appraisal for R1, facility staff documented R1’s vision as “good” and there was no indication regarding vision concerns involving R1. On the physician’s reports dated 7/13/20 and 3/22/22, R1 was listed as not having a visual impairment. During R1’s stay at BRVE, R1 had several appointments with the Optometrist due to decline/change in her vision, yet facility staff failed to update the changes in her medical condition and keeping the appraisal accurate.

Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times.This requirement was not met evidenced by: Based on interviews conducted, pest control document review, and physical plant inspection the facility had bed bugs beginning in June 2020- through at least Oct. 2020. This poses a potential health and safety risk to persons in care.

Maintenance and Operation. 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 On 05/20/22, at 9:33am upon LPA arriving at the facility, LPA tested the elevator by pressing the elevator button and observed the elevator to be in fuctioning and going up down, however the phone inside the elevator was not working and it is not known how long it has been in disrepair. R1 was trapped inside and phone did not function preventing R1 from calling for help

87415(a)(2) In facilities caring for sixteen (16) to one hundred (100) residents at least one employee shall be on duty on the premises, and awake. Another employee shall be on call, and capable of responding within ten minutes.This requirement is not met as evidenced by: Interviews with Residents and Staff indicate there were incidents which Staff did not response to Resident call switch in a timely manner.

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.This requirement is not met as evidenced by: During interviews with staff and residents, it was revealed that Staff #1 (S1) yells at residents. This poses an immediate Health, Safety, and/or Personal Rights risk to the residents in care.

87303 (a) Maintenance and Operation. 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 evidence by: During the course of this investigation, it revealed through interviews and records reviewed the facility has german roaches and bed bugs in the facility. LPA discovered that an exterminator treats only rooms 225, 102, 230 and 217 in the facility.