Marin Terrace

Allowing diabetic residents based on self-management ability

87628(a)Diabetes: licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens. This requirement is not met as evidenced by: Based on interviews & file review the licensee failed to ensure that resident (R1) was retained at the facility while not able to perform a glucose testing as per physician's report, but the facility did not followed up more than once to ensure R1’s glucose levels were monitored, which poses an immediate risk to the health and safety of residents in care.

Based on interview the licensee failed to have at least one staff member who has CPR and 1st Aid training on duty at all times. Facility has 3 out of 5 caregivers that work at the facility without a valid CPR certificate which poses a potential health, safety risk to residents in care.

Maintain facility in clean, safe, sanitary condition

Based on LPA's/Administrator observation and interview, the licensee did not comply with the section cited above in elevator was last inspected on 11/20/23 and permit expired on 11/20/24. Also, the auditory alarm when opening the door leading to second building located in the back of the facility was not working which poses/posed a potential health, safety or personal rights risk to persons in care.

Report specified resident events within seven days

Based on LPA’s record review and interviews with the Administrator, the facility failed to notify the Department about R1’s and R2’s incidents, which could pose a potential risk to the health and safety of residents in care.

Mark taps at high-temperature threshold

Based on the temperature reading of hot water facets not used by residents, the kitchen sink facet reading was 135.5 and 124 in the bathrooms which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in 4 out of 5 staff did not have required training completed which poses/posed a potential health, safety or personal rights risk to persons in care.

Require physician order and label for PRN medication

87465(e) Incidental Medical and Dental Care. For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication… Based upon statements, this requirement not met as evidenced by: An OTC sleep aid was observed in R1’s room which was not prescribed by R1’s physician. This posed an immediate risk to R1’s health.

Arrange appropriate medical and dental care

87465(a)(1) 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. ***Based on statements and documents, this requirement not met as evidenced by: R1 sustained rash for approximately 4 weeks prior to receiving medical treatment arranged by facility. This posed an immediate risk to the health of R1.

Call 9-1-1 for imminent health threats

(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis... This requirement was not met as evidenced by: based on document review and interviews conducted, the licensee did not comply with the section cited above by not contacting emergency services in a timely manner.

Fire approval and staff access to unlock systems

Based on observation, the licensee did not comply with the section cited above by leaving the door unlocked to the laundry room which stores toxic substances which poses an immediate health and safety risk to persons in care.

Provide resident hot water for personal care

Based on observation, the licensee did not comply with the section cited above in 5 out of 5 sinks accessible to residents in care which poses an immediate health and safety risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in 5 out of 5 persons which poses an immediate health, safety or personal rights risk to persons in care.

Residents in all facilities must have rights

Based on observation, the licensee did not comply with the section cited above by having cameras in 2 residents bedrooms which poses an immediate personal rights risk to persons in care.

Food quality controls and rejected damaged goods

Based on observation, the licensee did not comply with the section cited above by having expired canned foods which poses an immediate health risk to residents in care.

Based on observation, the licensee did not comply with the section cited above by not having staff in back cottage while resident(s) were in the building which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above by having exit doors not equipped with auditory devices which poses an immediate health, safety or personal rights risk to persons in care.

Ensure outdoor waste containers are cleanable

Based on observation, the licensee did not comply with the section cited above which poses a potential health risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in 4 out of 5 staff records reviewed which poses a potential health and safety risk to persons in care.

Include required health screening documents

Based on record review, the licensee did not comply with the section cited above in 2 out of 5 staff which poses a potential health and safety risk to persons in care.

Document behavioral expression and related causes

Based on record review, the licensee did not comply with the section cited above in 5 of 5 residents (R1, R2, R3, R4 and R5) who needs their care plan to be updated, which poses a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above by having residents whose beds are equipped with half rails without physicians orders on file which poses a potential health, safety or personal rights risk to persons in care.

Maintain cleanliness and prevent incontinence odors

Based on observation, the licensee did not comply with the section cited above by not ensuring that the facility remains free from odors from incontinence which poses a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in 5 out of 5 residents which poses a potential health, safety or personal rights risk to persons 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 incidents involving R1 after falls. Per hospice records revealed that R1 had incidents of falls and changes of conditions that were not reported to them nor CCL, which poses a potential health & safety risk to residents in care.

87464 Basic Services (f) Basic services shall at a minimum include: (3) Three nutritionally well-balanced meals and snacks made available daily, including low salt or other modified diets prescribed by a doctor as a medical necessity…This requirement has not been met as evidenced by Based on LPA’s observation, records review and interviews with the administrator revealing that facility was not providing meals that meet Recommended Dietary Allowances. This is a potential risk to residents in care.

Safe, healthful, comfortable accommodations

87468.1 Personal Rights of...(a) Residents in all RCFE shall have all of the following personal rights: (2) To be accorded safe, healthful & comfortable accommodations ...This requirement has not been met as evidence by: Based on LPAs observation and record review the facility failed to ensure resident's R1 personal rights where met when R1 was found unattended on the floor wearing only pull-up diaper, which poses a potential health and safety risk to residents in care.

Call 9-1-1 for imminent health threats

87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement has not been met as evidence by: Based on LPA’s records review and interviews. The facility staff failed to call 911 or other medical personnel as the hospice agency after R1 had a fall and changes of conditions, which poses an immediate health and safety risk to residents in care.

Facility personnel sufficiency and competence

87411 Personnel Requirements (a) Facility personnel shall at all times be sufficient in numbers, & competent to provide the services necessary to meet resident needs...ensure provision of personal assistance & care...This requirement has not been met as evidence by: Based on interviews conducted and records review. Facility staff did not assist R1 with shower & toileting as ordered by their physician supposedly due to their aggressive behavior after R1 came back from hospital, which poses an immediate risk to the health and safety of the residents in care.

§1569.269 Enumerated rights; severability (a) Residents of RCFE shall have all of the following rights: (6) To care, supervision, & 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 has not been met as evidence by: Based on LPA’s records review and interviews. The facility staff did not ensure that R1 was provided with adequate supervision by locking the back door of the main building blocking R1 from coming inside as well as staff not going to check on R1 every two-three hour as ordered by their physician, which is an immediate risk to the health and safety of residents in care.

§1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) 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 has not been met as evidence by: Based on LPA’s records review and interviews conducted with staff, the Administrator did not ensure that resident (R1) was assisted with proper care while residing in the facility, which poses an immediate risk to the health & safety of resident in care.

Reporting requirements

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 Executive Director did not ensure that CCL was notified of two incidents involving R1 after hospitalizations that occurred on 12/6/23 and 3/29/23 which poses a potential health & safety risk to residents in care.

Maintain separate complete record for each resident

87506(a)-Record Keeping:The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.This requirement was not met as evidenced by: Based on observation, during the Case Management-Deficiency inspection, LPA re-reviewed Resident #1's file and observed that there was no updated Care Plan in the resident record. Furthermore, this was previously cited on December 16, 2022 on Record Keeping.

Food handling safeguards during storage and service

87555 General Food Service Requirements:(b)The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement was not met as evidenced by:Based on a tour of the facility kitchen and the fridge, LPA observed three cans of whipped cream that had an expiration date of August 8, 2022.

87463(a)-Reappraisals:The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to:(b) The licensee shall immediately bring any such changes to the attention of the resident's physician and his family or responsible person.(c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement was not met as evidenced by:Based off of document reviews, there was no reappraisal completed for Resident #1 which presents a potential health, safety and personal rights risk to residents in care.

Personal assistance and care for required daily activities

87464(f)(4)-Basic Services:(f) Basic services shall at a minimum include:(4) 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. This requirement was not met as evidenced by:Based off document reviews of the Level of Care plan, the document indicated that the resident will be receiving regular bathes via two staff members and not sponge bathes. This regulation is a potential health, safety and personal rights risk to resident(s) in care.

87506(a)-Record Keeping:The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.Based off of document reviews, the facility did not retain a copy of the Admission Agreement in the file which presents a potential health, safety and personal rights risk to residents in care.

87211(b)-Reporting Requirements:(b) Any suspected physical abuse that results in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within two (2) hours as required by Welfare and Institutions Code Section 15630(b)(1). This requirement was not as evidenced by:Based off of interviews and a review of the SOC 341, the SUSPECTED elder abuse was not properly reported via an incident report or a SOC 341. This is an immeidate health, safety and personal rights risk to residents in care.