The Bluffs at Hamilton Hill

87705 Care of Persons with Dementia:(d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement, as defined in Section 87101, Definitions. This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, staff were not aware when R1 left the building and cleared the alarm without verifying which resident triggered it. This poses an immediate Health, Safety or Personal Rights risk to persons in care.

§1569.269 Enumerated rights... (a)Residents...shall have all of the following rights:(6) To care, supervision, and services that meet their individual needs...delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs........ ....This requirement was not met by licensee as evidenced by: Based on LPA record review of facility's pendant call button system log, R1s bell response time was 2 hours and 50 minutes and R2s bell response time was one hour, which poses a potentional risk to the health and safety of residents in care.

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..... This requirement not met by licensee as evidenced by: Based on document review, facility did not send an incident report to CCL for missed medication for R1 on October 16th and November 22nd, which poses an potential health and safety risk to residents in care.

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 record review, the facility did not ensure they had a med tech on duty resulting in R1 missing their medication, which poses an potential health and safety risk to residents in care. *civil penalty being assessed in the amount of $250.00**LIC9099D amended to reflect correct civil penalty amount*

Incidental Medical and Dental Care 87465(a)(4) The licensee shall assist residents with self-administered medications as needed.This requirement not met by licensee as evidenced by: Based on document review of MAR, R1 was not administered their prescription medication on October 16th and November 22nd which poses an immediate health, safety or personal rights risk to persons in care.

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 record review, the facility did not ensure staff on duty had training to dispense medication and/or had a med tech on duty which poses an potential health and safety risk to residents in care.

§1569.269 Enumerated rights... (a)Residents...shall have all of the following rights:(6) To care, supervision, and services that meet their individual needs...delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met by licensee as evidenced by: Based on LPA record review of facility's pendant call button system log, R1 bell response time was 19 minutes, 39 minutes, and 53 minutes which poses a potentional risk to the health and safety of residents in care.

87705 Care of Persons with Dementia:(d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement, as defined in Section 87101, Definitions. This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, Licensee did not ensure staff were aware when R1 left the building without assistance. This poses an immediate Health, Safety or Personal Rights risk to persons 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...This requirement is not met by licensee as evidence by record review and interviews...... conducted, the licensee did not ensure R1 received assistance from staff on duty and/or receive assistance in a timely manner. This poses an immediate Health, Safety or Personal Rights risk to persons in care.

87625 Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontience. This...... requirement is not met by licensee as evidence by record review and interviews conducted, the licensee did not ensure R1 had clean bedding as R1s mattress was saturated in urine. This poses a potential health, safety or personal rights risk to persons in care.

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......Based on record review of alarm response system, facility did not ensure that staff responded in a timely manner to..... ......call system to assist resident in care. Residents bell response time was 1 hour and 20 minutes, which poses a potentional risk to the health and safety of residents in care.

87411(a) Personal 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 failed to provide supervision to R1 resulting in an elopement. The absense of supervision is an immediate risk to the Health, Safety and Rights of resident in care.

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: (9)To have communications to the licensee from their representatives answered promptly and appropriately. This requirment is not met as evidenced by: Based on document review and interviews conducted, facility did not ensure communication with R1’s representative was answered promptly and appropriately as required by regulation. This poses a potential health and saftey risk to residents in care.

Based on document reviewed, the Licensee did not comply with the section cited above. Resident 1 (R1) eloped from facility and was found walking outside of community grounds in a nearby neighborhood . R1’s Physician Report states they have dementia. This poses an immediate health and safety risk to residents in care.

87211(a) A written report shall be submitted to the Licensing agency and to the person responsible for the resident within 7 days of the occurrence......Based upon documents reviewed, this requirement has not been met as evidenced by: R1 was transported for medical emergency on 4/22/24 and the Responsible Person was not notified by the facility. This posed an immediate risk to the personal rights of R1

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 has not been met as evidenced by: Based on interviews conducted, facility has insufficient staffing to provide the services necessary to meet the needs of the residents.

87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall... provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed. 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 medications being administered not as prescribed.

87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall... provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on document review, the licensee did not comply with the section cited above by R1 not being given medication as prescribed which poses an immediate health, safety or personal rights risk to persons in care.

87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall... provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on document review, the licensee did not comply with the section cited above by R1 not being given medication as prescribed which poses an immediate health, safety or personal rights risk to persons in care.

87211 Reporting Requirements (a)...licensee shall furnish to the licensing agency..., including...:(1) A written report shall be submitted to the licensing agency...within seven days of the occurrence of ...events specified in (A) through (D)...(D) Any incident which threatens the welfare, safety or health of any resident...This requirement was not met as evidenced by: Based on Incident report, the licensee did not comply with the section cited above by not reporting timely which poses a potential health and safety risk to persons in care.

87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall... provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on document review, the licensee did not comply with the section cited above by R1 not being given medication as prescribed which poses an immediate health, safety or personal rights risk to persons in care.

Based on file review and observations made, the Licensee did not comply with the section cited above for 2 of 2 residents. LPAs observed that medications for 2 residents were not administered as required. This poses a potential health and safety risk to residents in care.

Based on file review and observations made, the Licensee did not comply with the section cited above for 2 of 2 residents. LPAs observed that medications for 2 residents were not administered as required. This poses a potential health and safety risk to residents in care.

Based on Record Review and Observations made, Licensee did not comply with the section cited above and did not ensure that Staff Member 1 (S1) had the proper background clearance needed to work at the facility. This poses an immediate health and safety risk to residents in care.

Based on Records Review and Observations, the Licensee did not comply with the section cited above. LPAs observed that 2 of 6 staff files reviewed did not have a negative TB test on file. This poses an immediate health and safety risk to residents in care.

Based on Record Review and Observations made, Licensee did not ensure that Staff member 1 (S1), Staff Member 2 (S2) and Staff Member 3 (S3) had the proper background clearance needed to provide care at the facility. This poses an immediate health and safety risk to residents in care.

87411(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 observation, faciltiy failed to respond to resident care needs due to 2 caregiving staff found to have not been equipped with call pagers. In addtion, 3 out of 3 pagers were found to be inoperable. This poses as a potential health & safety risk to residents in care.