Greenwood Assisted Living

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 1 (R1) eloped from facility. R1’s Physician Report states they have dementia and are unable to leave unassisted. This poses an immediate health and safety risk to residents in care.

Right to sufficient care and qualified staff

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)...residents...shall have...personal rights:(4) To care, supervision, and services that meet...individual needs and...delivered by staff that are sufficient in numbers, qualifications, and competency... This requirement was not met as evidenced by: based on interviews conducted, records reviewed, and observations made, Licensee did not ensure that resident was assessed and emergency services sought. This poses an immediate health, safety or personal rights risk to persons in care.

87405 Administrator - Qualifications and Duties: (h)Administrator shall have the responsibility to: (5) Provide or ensure the provision of services to...residents with appropriate regard for... physical & mental well-being and needs... Requirement wasn't met as evidenced by: based on interviews, records reviewed, & observations, Administrator didn't ensure R1 received required services outlined in appraisal, by directing staff or updating care plan, when it was evident assistance w/ incontinence care was insufficient & they were notified. This poses an immediate health and safety risk.

Facility personnel sufficiency and competence

87411 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 was not met as evidenced by: based on interviews conducted, records reviewed, and observations made, Licensee did not respond to residents in a timely manner. This poses an immediate health, safety or personal rights risk to persons in care.

*Amended* 87633 Hospice Care of Terminally Ill Residents:(d)Licensee shall ensure... the hospice care plan is current... matches the services actually being provided, & that client’s care needs are being met at all times. Requirement was not met as evidenced by: based on interviews, records reviewed, & observations, staff failed to meet R1’s bladder & bowel needs based upon statements obtained during investigation which indicated R1 was found frequently to be in urine or bowel soaked briefs & soiled linens.This poses an immediate health & safety risk.

Each terminal resident needs a written hospice care plan

87633 Hospice Care of Terminally Ill Residents:(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility when all of the following conditions are met: (4) A written hospice care plan which specifies the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the facility is developed for each terminally ill resident or prospective resident by that resident’s hospice agency and agreed to by the licensee and the resident, or prospective resident, or the resident’s or prospective resident’s Health Care Surrogate Decision Maker, if any, prior to the initiation of hospice services in the facility for that resident, and all hospice care plans are fully implemented by the licensee and by the hospice(s).This requirement was not met as evidenced by:Based off interviews with witnesses, facility staff and observation of records provided by the Administrator, facility denied access for recertification of a resident on Hospice. This is an immediate health, safety and personal rights risk to the resident(s) in care.

This requirement is not met as evidenced by: LPA observed that 3 of 9 fire extinguishers service tags were outdated, expired, and last serviced on May 6, 2019. LPA did observe that 6 of 9 fire extinguishers were current and dated for November 1, 2021. This poses a potential health and safety risk to residents in care.

87455(a)(b)(2)-Acceptance and Retention Limitations:(a) Acceptance or retention of residents by a facility shall be in accordance with the criteria specified in this article 8 and Section 87605, Health and Safety Protection, and the following.(b) The following persons may be accepted or retained in the facility:(2) Persons receiving medical care and treatment outside the facility or who are receiving needed medical care from a visiting nurse.This requirement was not met as evidenced by: Based on interviews and LPA observation of records, it was determined Facility refused to admit 1 of 1 resident (R1) back from the Hospital in a timely manner. This poses an immediate health, safety or personal rights risk to persons 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.(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.This requirement was not met as evidenced by: Based on interviews with facility staff and research of incident reports for Greenwood Assisted Living, the facility did not report an Unusual Incident Report (LIC 624) regarding a fall and subsequent hospitalization to the Department. This poses a potential health, safety or personal rights risk to persons in care.