New Bethany

Based on observation, interview, & record review, the licensee did not comply with the section cited above in 3 out of 7 resident files did not have a written personal property inventory which poses/posed 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 in which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed ice machine to have mildew/build up on the inside and hard water build up on the outside, water dispenser in activity room has hard water build up on dispenser tray.

Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed scissors, hand pruners, and insect killer in unlocked closest in the activity room. LPA observed cleaning/disinfectant in unlocked utility closet in activity room. LPA observed laundry detergent accessible to residents under the sink in a laundry room.

Based on observation & record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA reviewed staff records and 5 staff records did not have the TB test results in the files.

Based on observation, & record review, the licensee did not comply with the section cited above in 5 out of 5 staff files which poses/posed a potential health, safety or personal rights risk to persons in care. Training documentation does not reflect number of hours conducted on training.

Based on observation, interview, & record review, the licensee did not comply with the section cited above in 2 out of 7 resident physician reports do not have a diagnosis listed which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, interview & record review, the licensee did not comply with the section cited above in 4 out of 7 resident files did not have a current physician's report which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA reviewed R1's centrally stored medication log which did not have a start date for Tamsulosin 0.4MG & Atorvastatin Calciui/40MG.

Based on observation, interview, & record review, the licensee did not comply with the section cited above in 3 out of 7 resident files did not have a pre-admission appraisal which poses/posed 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, 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.This requirement is not met as evidenced by: Based on observation, interview, & record review the licensee did not comply with the regulation listed above. LPA was provided internal incident reports which were not reported to the Dept.

Based on observation, interview, record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. Medication count for R1 was marked as been given and was still in bubble pack.

Based on observation, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care. Water read at 125.2 degrees Fahrenheit in the common bathroom in the D wing.

Based on observation & interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed kitchen in activity room to be unlocked with knife and chemicals accessible to residents.

80075 Health Related Services(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.(2) Facility staff, except those authorized by law, shall not administer injections but staff designated by the licensee shall be authorized to assist clients with self-administration of injections as needed.This requirement is not met as evidenced by: This requirement is not met as evidenced by: Based on observations, interviews, & record review(s), the licensee failed to only allow licensed professionals administer injectable medications. R1 was not able to communicate how they give their own injection, staff schedule indicates no licensed professional staff at the facility after 2:00 p.m., physician report states R1 is not able to administer their own injectable medication.This poses an immediate Health, Safety or Personal rights risk to residents in care.

87465 INCIDENTAL MEDICAL AND DENTAL CARE SERVICES 87465 (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on interviews and reviews of evidence, licensee failed to arrange for medical care appropriate to the conditions and needs of resident. R1 did not receive proper care resulting in falling and sustaining a closed C2 fracture and a right vertebral artery dissection which poses an immediate health; safety or personal rights risk to residents in care.

87466 OBSERVATION OF THE RESIDENT 87466 The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: Based on interviews and reviews of evidence, licensee failed to ensure that such changes are documented and brought to the attention of the resident’s (R1) physician. Therefore, R1 did not receive needed medical care and treatment which poses an immediate health; safety or personal rights risk to residents in care.

Personnel Requirements – General All personnel shall be given on the job training…This training and/or related experience shall provide knowledge of and skill…by safe and effective job performance, Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents.This requirement was not met: Based on observation, at 1: 56 p.m and 2:32 pm., Licensing Program Analyst and Administrator observed residents’ call buttons not being responded by staff in a timely matter upon activation which poses a potential health and safety and personal rights risk to the person in care.

87464 Basic Services:(f)shall at a minimum include:(1)Care and supervision as defined...Health and Safety Code section 1569.2(c)"Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. This requirement was not met as evidenced by: Based on interviews and record reviews, the licensee did not take necessary measures or provide adequate supervision to prevent R1 from sustaining a fall on 11/25/2020.

87455 Acceptance and Retention Limitations: (c) No resident shall be accepted or retained if any of the following apply: (2) The resident requires 24-hour, skilled nursing or intermediate care...This requirement was not met as evidenced by: R1 was admitted to the hospital from the facility on 10/23/2020 with multiple stage 3 and 4 pressure injuries and severe malnutrition. Facility staff stated that R1 required a higher level of care.