Pasadena Highlands

Based on observation, the licensee did not comply with the section cited above in rodent droppings were observed underneath the shelfing units in the corners by the walls. which poses an immediate 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 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 deficiency is evidenced by the following:'R1 pulled on pull cord several times for assistance and staff failied to enter room resulting in R! having to call 911.

Based on observation, the front desk did not comply with the section cited above in 2 of 2 counts which poses an immediate health, safety or personal rights risk to persons in care. Front dest staff did not screen for COVID-19 symptons or check temperture of LPAs when greeted at arrival to facility.

Personnel Requirements-General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.This requirement was not met by evidence of: Based on record review and interviews conducted between October 2021- January 2022 the facility has experienced staffing shortages. Resident (R1) required total care, but was not being checked by staff as indicated in the re-assessment.This poses a potential health and safety risk to residents in care.

Basic Services. Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports. Based on record review and interviews conducted resident (R1) required repositioning, incontinence care, and feeding assistance after return from hospitalization. R1 had a change in condition due to injury sustained on 10/20/21. Assistance was not provided in a timely manner. This poses a potential health and safety risk to residents in care.

Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed.This requirement is not met as evidenced by: Based on interviews conducted and record review on Jan. 1, 2022 (R1) was not administered evening medication as directed by MD. The meidications were administered late, were not crushed, and the wrong inhaler was taken to the room. Staff (S6) acknowledged medication error. This poses an immediate health and safety risk.

Additional Personal Rights of Residents in Privately Operated Facilities. In addition to ... 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: 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 is not met as evidenced by:Based on interviews and record review resident (R1) fell in the lobby area on 10/20/21. R1 was without assistance, but per Care Plan R1 requires escort assistance. This poses a potential Health and Safety risk to residents in care.

Reporting Requirements. Within 24 hours the licensee shall notify the licensing agency (and the local health officer, if appropriate) if an epidemic outbreak, poisoning, catastrophe or major accident which threatens the welfare, safety, or health of residents, personnel or visitors occurs. Facility had outbreak of Covid -19 (first of 12 individuals tested positive on 12/25/2021 and not reported untill 01/12/2022) and did not report to health department and licensing agency as required

1569.33(i)(1)(2) Unannounced inspections; notification of deficiencies; compliance; reports. The department shall design, or cause to be designed, a poster that contains information on the appropriate reporting agency in case of a complaint or emergency.Each residential care facility for the elderly shall post this poster in the main entryway of its facility. Based on physical plant observation with Health and Wellness Director a complaint poster with DSS/CCLD complaint phone number was not observed in the 1st and 2nd floor main entryway areas.

87705(j) Care of Persons with Dementia. The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.This requirement was not met by evidence of: Based on observation at 10:59 am during the delayed egress door testing in the memory care unit, as a part of a complaint investigation it was observed the right door did not open after the delayed egress time of 15 seconds. In addition, the alarm did not sound off on that door. The left side door was operable. This poses an immediate health and safety risk.

87411(a) Personnel Requirements-General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.This requirement was not met by evidence of: On June 4, 2021 at approximately 1:30 pm resident (R1) eloped out of the facility after exiting the memory care unit delayed egress door without staff knowlede when staff (S6) exited out, and did not ensure the door closed properly. This posed an immediate safety risk to this resident in care.

87411 PErsonnel Requirements-General(a) (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.The requirment is not met as evidenced by LPA’s interview and reported residents had to wait for 25mints to an hour to be assisted and facility usually has about 4-5 caregivers on one floor but now there’s only one or two on the floor which pose a potential health and safety risk to residents in care