Linda Falls Guest Home 1

Staff training; legislative findings; contents1569.625(b)(1)....A staff member shall complete 20 hours...before working independently with residents. The remaining 20 hours... shall be completed within the first four weeks of employment.This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above where S1's personnel file was observed missing proof of all of the required initial training which poses a potential health, safety and/or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in 2 out of 3 staff files reviewed which were missing proof of the required annual medication training which poses a potential health, safety or personal rights risk to persons in care.

87457 Pre-Admission Appraisal: (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This requirement is not met as evidenced by: Based on records reviewed, Licensee did not complete an evaluation of residents condition prior to admission and keep it in the file. This poses a potential Health, Safety or personal rights risk to persons in care.

87458 Medical Assessment: (a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record. This requirement is not met as evidenced by: Based on records reviewed, Licensee did not ensure R1 received a medical assessment prior to admission. This poses a potential Health, Safety or Personal rights risk to persons in care.

87224 Eviction Procedures: (f) A written report of any eviction shall be sent to the licensing agency within five (5) days. This requirement is not met as evidenced by: Based on records reviewed, Licensee issued an eviction on 09/24/2024 to R1 and did not forward a copy to CCLD. This poses a potential Health, Safety or Personal rights risk to persons in care.

87303 Maintenance and Operation: (b)A comfortable temperature for residents shall be maintained at all times.(1)The facility shall heat rooms that residents occupy to a minimum of 68 degree F, (20 degrees C). This requirement is not met as evidenced by: Based on thermometer reading during visit, Licensee did not ensure the temperature was at least 68 degrees F. Temperature was 67 degrees. This poses a potential Health, Safety or Personal rights risk to persons in care.

87466 Observation of the Resident: 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. This requirement is not met as evidenced by: Based on records reviewed, LIcensee did not ensure resident received ongoing medical care for a worsening wound, resulting in residents hospitalizion. This poses an Immediate Health, Safety or Personal Rights risk to persons in care. An immediate Civil Penalty is being issued in the amount of $500.

87465 Incidental Medical and Dental Care: (2) The licensee shall provide assistance in meeting necessary medical and dental needs. This requirement is not met as evidenced by: Based on records reviewed, Licensee did not ensure R1 received timely medical care for a worsing wound. This poses an Immediate Health, Safety or Personal Rights risk to persons in care.

Based on LPA observation and record review, the licensee did not comply with the section cited above in that facility does not have a Centrally Stored Medication List on File for Residents in care, 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 in that LPA observed kitchen pantry cabinet where food was stored to have multiple rodent droppings on every shelf, underneath the kitchen sink and where the potatoes were stored 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 that LPA observed the kitchen pantry cabinet to have multiple food items to be expired. (Kikkoman sweet cooking seasoning exp 12/4/2023, Organic coconut aminos sauce exp 7/6/2021, Worcestershire sauce exp 2/20/2021, Bulls Eye bbq sauce exp 10/11/2020, Sugarman Maple syrup exp 1/17/2020, Sweet chili sauce exp 4/9/2021, chili beans exp 4/21/23, Kraft Parmesan cheese exp 4/23/23 and 9/12/21). Refrigerated food was not found to be stored in a safe manner with open items not labeled with opened date which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above in that S1, S2, S3 had no required annual training on file, 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 that water temperature in sinks accessible to residents in care measured at 101.8, 103.6, 138.2 degrees F, which is not within the allowable range of 105 to 120 degrees F. which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above in R1 does not have a current LIC602 and Appraisal Needs and Services Plan which poses/posed a potential health, safety or personal rights risk to persons in care.

Per LPA observation and record review, the licensee did not comply with the section cited above in that one non-ambulatory, R2 resident is located on the second level of the facility, however fire clearance prohibits non ambulatory residents on the second floor, which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above in that R2, R4, R5, R6 do not have a current Appraisal Needs and Services Plan on file, which poses/posed a potential health, safety or personal rights risk to persons in care.

87465(h)(2) Incidental Medical and Dental Care-Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met, as evidenced by: LPA observed a large container of several prescribed medications, as well as over the counter medications, of R1, out in the open, not locked up, This is an immediate health and safety risk to residents in care.

Emergency Plans 1569.695 (a)(d) (1)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary. An evacuation chair at each stairwell. This requirement was not met as evidenced by: LPA observed three non-ambulatory residents on the upper level. LPA observed the facility does not have fire/emergency exits per LPA's inspection, the facility only has stairs inside on the upper floor and outside stairs from the balcony, this is a health and safety risk to residents in care.

87307 Personal Accommodations and Services (d)(4)-The following space and safety provisions shall apply to all facilities: Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents.This requirement was not met, as evidenced by: LPA observed there are three (3) residents on the upper level, two (2) residents have/use walkers, and one (1) resident is wheelchair bound. LPA observed the inside upper-level stairs has no barrier, and the upper-level outside balcony stairs has no barrier, this is a health and safety risk to residents in care

Per record reviews, Three out of Four staff lack required annual training, the licensee did not comply with the section cited above in [3] out of [4] staff] which poses/posed a potential health, safety or personal rights risk to persons in care.

LPA observed that two resident rooms with very dirty carpet, one room is on the upstairs level, and the other is on the downstairs level, the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.

LPA observed a resident room to have a strong urine odor as soon as the resident's door was opened, the licensee did not comply with the section cited above in [1] out of [3] resident rooms] which poses/posed a potential health, safety or personal rights risk to persons in care.

Per file review and observations by the LPA, facility is fire cleared for four ambulatory, and two(2) non-ambulatory only. Licensee has a two additional non-ambulatory residents, and a bedridden resident admitted into the facility, which is out of compliance with the approved fire clearance, the licensee did not comply with the section cited above in [3] out of 3] admitted residents] which poses an immediate health, safety or personal rights risk to persons in care.

Per record review, three out of four staff/caregivers lack current First Aid; Three out of four staff lack current CPR certification the licensee did not comply with the section cited above in [3] out of (4] which poses an immediate health, safety or personal rights risk to persons in care.

87615(a)(1) Prohibited Health Conditions. Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: Stage 3 and 4 pressure injuries. This requirement was not met as evidenced by: Based on record review, resident was admitted to the hospital with an unstagable wound. Facility retatined a resident with a prohibited health condition without notifying CCL which posed a potential health and safety risk to resident in care.