Morningstar of Pasadena

Based on record review, the licensee did not comply with the section cited above in 4 out of 10 residents did not have an appraisal done within the last 12 months which poses/posed a potential 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 in 1 out of 10 residents, R6 had a as needed prescribed medication out of original container which 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 (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 observation, interviews conducted and file review, it was revealed that R1 was left unattended in the facility van from 3:00 pm to 8:45 pm, which poses an immediate health, safety, or personal rights risk to persons in care.

87468.2(14)Additional Personal Rights of Residents in Privately Operated Facilities-To reasonable accommodation of their individual needs and preferences in all aspects of life in the facility, except when accommodation would endanger the health or safety of the individual resident or other residents. This requirement is not met as evidence by:Facility placed R1 in memory care unit eventhough R1 does not require memory care assistance or have a MCI diagnosis.

87303 Maintanance 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 was not met as evidence by:R1 had flooding in room coming from kitchen sink which caused plumbing issues and flooding.

87303 Maintanance 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.

87211 Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: 1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

87468.2(14)Additional Personal Rights of Residents in Privately Operated Facilities-To reasonable accommodation of their individual needs and preferences in all aspects of life in the facility, except when accommodation would endanger the health or safety of the individual resident or other residents. This requirement is not met as evidence by:Facility placed R1 in memory care unit eventhough R1 does not require memory care assistance or have a MCI diagnosis.

87211 Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.(2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.This requirement was not met as evidence by: Licensee failed to notify this licensing agency that between 6-3-23 through 6-17-23, twenty-two (22) residents tested positive for COVID-19. From 6-4-23 through 6-17-23, four (4) facility staff tested positive for COVID-19. From 6-17-23 through 6-23-23, thirteen (13) additional residents tested positive for COVID-19. This licensing agency did not receive any written reports within seven (7) days of occurrence in reference to this recent epidemic outbreak, which began on 6-3-23.

87470Infection Control Requirements(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.(1) All staff and volunteers shall perform hand hygiene. Staff shall demonstrate knowledge of and skill in infection control, as appropriate to the job assigned and as evidenced by safe and effective job performance.This requirement is not met as evidence by: Licesee did not adhere to mitigation plan in regards to responding to outbreak of COVID-19.

87415 (3)Night Supervision(3) In facilities caring for one hundred one (101) to two hundred (200) residents, one employee shall be on call, on the premises; one employee shall be on duty on the premises and awake; and one employee shall be on call and capable of responding within ten minutes.This requirement was not met as evidenced by: Emergency Fire personnel arrived at facility and could not access the facility because there was no one at the front desk to let them in and had to contact resident via phone to allow them entry. No staff was available at that time to allow the Fire Department Entry which poses a health and safety hazard for residents in care.

a) The department may deny an application for a license or may suspend or revoke a license issued under this chapter upon any of the following grounds and in the manner provided in this chapter:(3) Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California. This requirement is not met as evidenced by:Upon arriving at the facility at 10:30 am LPA was greeted by Staff #1 (S1) and LPA was not screened for COVID upon entering the facility. This poses an immediate health and safety risk to persons in care.

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require,...: (2) Occurrences, such as epidemic outbreaks,... or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported... to the licensing agency and to the local health officer when appropriate. Based on interviews, the Executive Director did not ensure that the Pasadena Public Health Department receives their weekly required lab reports for unvaccinated staff and residents which poses a potential health and safety risks to residents in care.