Aldersly

Grounds for eviction listed for residents

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 required...This requirement was not met as evidenced by: based on record review, interviews, and observations, Licensee did not ensure that R1 received a proper eviction after it was identified they required a higher level of care. This poses a potential health, safety, and/or personal rights risk to residents in care.

Based on medication review, Licensee did not comply with the section cited above. Licensee did not ensure that resident medication was centrally stored as required. This poses/posed a potential health, safety or personal rights risk to persons in care.

Store centrally held medications in locked secure place

Based on observations made, Licensee did not comply with the section cited above. Licensee did not ensure that medications were locked and inaccessible. This poses/posed a potential health, safety or personal rights risk to persons in care.

Right to sufficient care and qualified staff

Based on record review, Licensee did not comply with the section cited above and did not ensure R1 was helped in a timely manner when facility staff were alerted to their fall from the Safely You Video System. Report stated that video footage showed R1 on the floor for over 2 hours. This poses an immediate health and safety risk to residents in care.

Night supervision when dementia residents require it

This requirement is not met as evidenced by: Based on record review, Licensee did not comply with the section cited above. Resident 3 eloped from facility. R3's Physician Reports state they are unable to leave without assistance and has a diagnosis of dementia. This poses an immediate health and safety risk to residents in care.

Night supervision when dementia residents require it

87705 Care of Persons with Dementia: (b) In addition to the requirements as specified in Section 87208... plan of operation shall address... residents with dementia, including: (2) Safety measures to address behaviors such as wandering...This requirement is not met as evidenced by: Based on documents reviewed, the Licensee did not comply with the section cited above. Resident 2 (R2) eloped from facility and was found 2 blocks away. R2’s Physician Report states they have dementia. This poses an immediate health and safety risk to residents in care.

Night supervision when dementia residents require it

Based on File Review and Observations made, the Licensee did not comply with the section cited above. Licensee reported R1 to be missing during a community outing where R1 was not found until approximately 7 hours later. Review of R1’s Physician Report indicates that they have a diagnosis of dementia. This poses an immediate health and safety risk to residents in care.

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require…(1) A written report shall be submitted to the licensing agency & person responsible for the resident within 7 days of the occurrence of any of the events…(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement has not been met as evidence by: Based on LPA’s records review and interviews conducted Administrator did not ensure that CCL was notified of two incidents involving R1 after falls that occurred on 12/6/22 and 12/30/22 which poses a potential health & safety risk to residents in care.

Modified diets for medical necessity

87555 General Food Service Requirements: (b) The following food service requirements shall apply: (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement has not been met as evidence by: Based on LPA’s records review and interviews with facility staff, the facility did not ensure that staff was assisting resident (R1) with their modified diet care plan as prescribed by their Physician. This poses an immediate health & safety risk to the residents in care.

Reporting requirements

87211 Reporting Requirements:(a)Each licensee shall furnish to the licensing agency such reports as the Department may require, including...the following:(1)A written report shall be submitted to the licensing agency...within seven days of the occurrence of...(D)Any incident which threatens the welfare, safety or health of any resident... This requirement is not met as evidenced by:Based on Record Review, the Licensee did not comply with the section cited above, and did not submit reports to CCL as required. This poses a potential health and safety risk to residents in care.

Facility personnel sufficiency and competence

87411(a) 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… This requirement has not been met as evidenced by: Based on records reviewed and interviews conducted, facility staff were unable to respond to resident care needs and call buttons in a timely manner. Records reviewed indicated that multiple call buttons had response times of an hour or longer. Interviews stated that there was an issue with facility pendants not working properly. This poses an immediate risk to the health and safety of residents in care.

Protection from punishment and intimidation

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:(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 was not met as evidenced by:During a tour of the facility, LPA observed a trash bag on R1's closet that prevents R1 from obtaining clothing to wear. This presents an immediate health, safety and personal rights risk to residents in care.

Reporting requirements

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.(A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility.(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.(C) The use of an Automated External Defibrillator.(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met evidenced by:Based on interviews with facility staff, and research of incident reports submitted to CCL, facility did not properly report an incident to the CCL as required by Title 22 regulation. This poses a potential health, safety or personal rights risk to persons in care.