Aegis Living Corte Madera

Provide resident hot water for personal care

Based on observations made, Licensee did not comply with the section cited above. 7 of 10 facility sinks were found to be out of compliance with Title 22 Regulations, measuring at 125.6F, 125.2F, 122.5F, 123.0F, 121.8F, 120.3F, 120.2F. This poses an immediate health, safety or personal rights risk to persons in care.

Diet quality and preparation in safe healthful manner

Based on observations made, Licensee did not comply with the section cited above. LPA observed expired yogurt in facility's memory care fridge located in Lee's Lane Memory Care. 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. LPA observed two residents with medications in their room that should have been centrally stored and inaccessible. This poses an immediate health, safety or personal rights risk to persons in care.

Assist residents with self-administered medication

87465 Incidental Medical and Dental Care (a) A plan for incidental medical... shall be developed...by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.This requirement is not met as evidenced by: Based on interview & record review, the licensee did not comply with the section cited above in that medications for resident R3 were given to resident R2, which poses an immediate health, safety or personal rights risk to persons in care.

Right to sufficient care and qualified staff

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights...: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are...to meet their needs. This requirement is not met as evidenced by: Based on interview & record review, the licensee did not comply with the section cited above in that R1's Individualized Service Plan was not followed when R1 was transferred by only one (1) staff member which poses a potential health, safety or personal rights risk to persons in care.

Limit staff assistance with self-administered drugs

87465(a)(5): Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed.This requirement is not met as evidenced by: Based on record review and interview with HSD, the facility did not ensure R1, R2, & R3’s medications were given as prescribed by doctor as pharmacy did not send monthly refills on time which is also a pharmacy error which poses an immediate health and safety risk to resident in care.

Facility personnel sufficiency and competence

87411(a) Personnel Requirements - General 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 evidence by: Based on incident report and interview, facility did not provide supervision to R1 resulting in an elopement. The absence/lack of supervision is an immediate risk to the Health, Safety and Rights of resident in care

Based on record review, the licensee did not comply with the section cited above in not submitting 6 Required Incident Reports to CCL, which poses/posed a potential health, safety or personal rights risk to persons in care.

Ensure hazardous items are locked and not unattended

Based on LPA & Interim Administrators observations during Annual Inspection, the licensee did not comply with the section cited above in finding 4 storage closets ( in MC & AL) unlocked containing multiple gallons of pain, toxic chemicals, cement, cleaning products, etc.. which poses an immediate health, safety or personal rights risk to persons in care.

Provide resident hot water for personal care

Based on LPA & Interim Admin's observation & interview during annual inspection, the licensee did not comply with the section cited above in 14 out of 15 faucets used by resident in care measured between 120.2 degrees F & 132 degrees F. which poses an immediate health, safety or personal rights risk to persons in care.

Night supervision when dementia residents require it

87705(b)(2) Care of Persons with Dementia: Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. Not met as evidence by** Based on record review it was found that resident (R1) had been reported by facility to be missing from facility care. R1 is diagnosed with dementia and based upon Physicians Report, requires special supervision for confusion and wander risk. This is an immediate health & safety risk to resident in care.

Limit staff assistance with self-administered drugs

87465(a)(5): Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed.This requirement is not met as evidenced by: Based on record review and interview with GM & HSD, the facility did not ensure R1 medications were given as prescribed by doctor which poses an immediate health and safety risk to resident in care.

Provide resident hot water for personal care

Based on LPAs and Licensee observation, the licensee did not comply with the section cited above in one memory care residents faucet was only 67 degrees F , which poses a potential health, safety or personal rights risk to persons in care.

Notify agency before locking doors or gates

Based on LPAs & General Manager's observation, the licensee did not comply with the section cited above when touring memory care courtyard observed large shards of broken glass on the ground by walkway accessible to residents in memory care, which poses an immediate health, safety or personal rights risk to persons in care. Maintance remived immediately.

Fire approval and staff access to unlock systems

Based on LPAs and General Managers observation, the licensee did not comply with the section cited above when touring memory care kitchenette finding Clorox toilet cleaning in unlocked cabinet which poses an immediate health, safety or personal rights risk to persons in care.

Health screening and fitness requirements

Based on LPA's interview & record review, the licensee did not comply with the section cited above in 1 out of 5 staff did not obtain Health Screening test & TB test results which poses/posed a potential health, safety or personal rights risk to persons in care.

Maintain facility in clean, safe, sanitary condition

Based on LPA and General Manager's observation, the licensee did not comply with the section cited above in that a memory care residents bathroom window (that was open without a censor) did not contain required window screen, which poses/posed a potential health, safety or personal rights risk to persons in care.

Limit staff assistance with self-administered drugs

87465(a)(5): Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed.This requirement is not met as evidenced by Based on record review and interview with GM & HSD, the facility did not ensure R1-R2 medications were given as prescribed by doctor on 2 different incidents which poses an immediate health and safety risk to resident in care.

Night supervision when dementia residents require it

87705(b)(2) Care of Persons with Dementia: Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. Not met as evidence by Based on a record review & interview with GM it was found that resident (R5) had been reported by facility to be missing from facility care. Medical documents indicate diagnosis of dementia.

Limit staff assistance with self-administered drugs

87465(a)(5): Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed.This requirement is not met as evidenced by: Based on record review and interview with GM & HSD, the facility did not ensure R1-R4 medications were given as prescribed by doctor on 4 different incidents which poses an immediate health and safety risk to resident in care.

Give PRN medication by physician order

87465 (c )(2) Incidental Medical & Dental Care 87465(c)(2) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Based on self-report submitted by facility, a staff, provided another resident’s PRN pain medication to a resident, not administering PRN medication to R1 as prescribed by their Physician which is an immediate Health and Safety risk to the resident(s) in care.

Assist residents with self-administered medication

87465(a)(4) Incidental Medical and Dental Care… The plan shall… provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self administered medications as needed. *** Based on statements and documents, this requirement not met as evidenced by: PRN medication ordered by physician for R1 was not administered on 9/12/23. This posed an immediate risk to R1’s health. $250.00 Civil Penalty issued for repeat violation within 12 months.

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 was not met as evidenced by: Based on LPA interview’s and record review facility has delayed call response for residents using their pendants. From 3/1/2023-3/20/2023 reflect at least six hundred and fifty-four response times between 10-30 minutes, and at least 66 response times between 30-60 minutes, and at least 43 response times that were more than 60 minutes or never responded to. This is an immediate risk to the Health, Safety and Personal Rights of residents in care.

Limit staff assistance with self-administered drugs

87465(a)(5): Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed. This requirement is not met as evidenced by:Based on record review and interview with Director of Operations, the facility failed to ensure R1-R13 medications were given as prescribed by doctor (not provided at evening med pass) which poses an immediate health and safety risk to resident 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 was not met as evidenced by: Based on LPA interview’s and record review facility has delayed call response for residents using their pendants. From1/23/2023-2/3/2023 reflect at least three hundred and one response times between 10-30 minutes, and at least 37 response times between 30-60 minutes. This is an immediate risk to the Health, Safety and Personal Rights of residents in care.

Night supervision when dementia residents require it

87705(b)(2) Care of Persons with Dementia: Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. Not met as evidence by** Based on a review records it was found that resident (R1) had been reported by facility to be missing from facility care. Medical documents indicate diagnosis of dementia.

Assist residents with self-administered medication

Based on interview and record review, the licensee did not comply with the section cited above where resident was not assisted with eyedrops per doctors orders, which poses an immediate health, safety or personal rights risk to persons in care.

Maintain facility in clean, safe, sanitary condition

Maintenance and Operation 87303 (a)(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: Based on LPA's Interviews, and record review facility did not comply with the section cited above in maintaining the facility in good repair and keeping residents call devices in working order, which poses/posed a potential health, safety or personal rights risk to persons in care.

Facility personnel sufficiency and competence

87411(a) Personnel Requirements - General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on interviews and record reviews, the licensee/Administrator did not ensure staff was competent and or knowledgeable to be able to administer per doctor orders. Staff could not find the mask needed which is an immediate risk to the health and safety of residents in care.