Follow-up on corrections·February 18, 2025

Citations

6 citations recorded^*CCLD

• 87464(f)(1)Type B

  Basic Services. Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).This requirement was not met evidenced by: Based on record review and interviews conducted, the findings indicate that on7/31/2024 (R1) sustained a right hand injury while the resident was transferred from the shower chair to the toilet by 1 staff instead of 2 staff, which posed an immediate health and safety risk to the resident.

• 87465(a)(1)Type B

  Incidental Medical and Dental Care...The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.This requirement was not met evidenced by: Based on interviews and records review, facility staff did not comply with the section above. On 7/31/2024, R1 sustained a hand injury at 7AM, and med-tech staff failed to arrange for timely medical attention which resulted in R1 being transported to the hospital until after 10 PM. This posed an immediate health and safety risk to resident in care.

• 87465(a)(5)Type A

  Incidental Medical and Dental Care Services. A plan for incidental medical and dental care shall be developed by each facility…..the licensee may assist persons with self-administration as needed. This requirement is not met as evidenced by: Based on interviews and MAR record review, med-tech staff failed to order and obtain a refill for “Latanoprost 0.005 %” eye drops and on 7/6/24 asked family to order the refills and pick up the medication. Additionally, on 8/8/24 medication Donepezil HCL 5mg was not administered at the physician order time, and was given at 6 PM, instead of bedtime. This posed an immediate health and safety risk to the resident in care.

• 87468.1(a)(2)Type B

  Personal Rights of Residents in All Facilities. Residents in all residential carefacilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on interviews, during (Jun 2024-Aug. 2024, PM staff were not locking the front doors at 7 PM as required. On 8/3/24, at midnight R1’s family stopped by the facility to check if the front doors were locked. They were found unlocked. On 8/1/24, Administration staff were notified of the concern. This posed a potential health and safety risk to residents in care.

• 87625(b)(3)Type B

  Managed Incontinence.... the licensee shall be responsible for the following:Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met evidenced by: Based on record review and interviews the findings indicate that on multiple dates R1 was not provided incontinence care at least every 2 hours as required, and on 8/10/24, R1’s bed sheets were soiled with urine and the resident had not received incontinence care. This posed a potential health and safety risk to the resident in care.

• 87211(a)(B)Type B

  Reporting Requirements. Each licensee shall furnish to the licensing agency such reports..... 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.... Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement was not met evidenced by:On 7/31/2024, resident (R1) sustained a right hand injury that resulted in an open flesh wound tear of approximately 4 inches, while the resident was transferred from the shower chair to the toilet. Facility faxed the incident report until 8/14/24, which posed a potential health and safety risk.

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