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Provide copies of signed agreements and amendments

87507 Admission Agreements:(e) The licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative, if any, immediately upon signing the admission agreement or modification. This requirement is not met as evidenced by: Based on interviews conducted, resident nor their representative received a copy of the admission agreement immediately after signing. This poses a potential Health, Safety or Personal rights risk to residents in care.

Prompt responses to resident communications

87468.1 Personal Rights of Residents in All Facilities: (9) To have communications to the licensee from their representatives answered promptly and appropriately. This requirement is not met as evidenced by: Based on interviews conducted, Licensee did not promptly respond to resident representatives This poses a potential personal rights risk to residents in care.

87608 Postural Supports (a)(5)(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Based on file review, interviews conducted and record review, the licensee was unable to produce orders for full bedrails observed on R1's hospital bed as required per regulation, which poses a potential health, safety, and/or personal rights violation to residents in care.

Assist residents with self-administered medication

87465 Incidental Medical and Dental Care:(4) The licensee shall assist residents with self-administered medications as needed.This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, Licensee did not ensure medications were administered as ordered. Resident did not receive eye drops as ordered and resident antibiotics were not given as ordered. This poses an immediate Health risk to residents in care.

85068.2(b) Needs and Service Plan. If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan…..***Based upon records reviewed, this requirement has not been met as evidenced by: Appraisal & Needs Service Plan for 5 out of 5 residend as of 04/01/2025 is not complete or signed by all partiesThis poses a potential Health and Safety risk to clients in care.

§1569.269 Enumerated rights; severability (a)(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 is not met as evidenced by: Based on file review, interviews conducted and record review, the licensee did not ensure that facility was staffed sufficiently or that staff were competently trained to ensure injuries were not caused to R1 during their care, which poses a health, safety, and/or personal rights violation to residents in care.

H&S Code 1569.625 Staff training; legislative findings; contents: training requirements . This requirement is not met as evidenced by: ***Based on file review & interview with Licensee, the licensee failed to ensure that all staff had completed the required annual training as required by title 22 regulations and H&S Code which poses a potential health and safety risk to residents in care. LPA observe during file reviews 3 out of 3 staff have not completed all of the required 20 hours of ongoing annual training.

87211 Reporting Requirements:(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by: Based on records reviewed Licensee did not follow regulation by not notifying the Department of a residents visit to the emergency room. This poses a potential Health, Safety or Personal rights risk to residents in care.

Document required staff training and orientation

87412 Personnel Records:(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not met as evidenced by: Based on records reviewed, Licensee did not have documentation of completed staff training. This poses a potential Health, Safetly or Personal Rights risk to residents in care.

§1569.269 Enumerated rights; severability (a)(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 is not met as evidenced by: Based on file review, interviews conducted and record review, the licensee did not ensure that facility was staffed sufficiently or that staff were competently trained to ensure injuries were not caused to R1 during their care, which poses a health, safety, and/or personal rights violation to

87608 Postural Supports (a)(5)(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Based on file review, interviews conducted and record review, the licensee was unable to produce orders for full bedrails observed on R1's hospital bed as required per regulation, which poses a potential health, safety, and/or personal rights violation to residents in care.

H&S Code 1569.625 Staff training; legislative findings; contents: training requirements . This requirement is not met as evidenced by: ***Based on file review & interview with Licensee, the licensee failed to ensure that all staff had completed the required annual training as required by title 22 regulations and H&S Code which poses a potential health and safety risk to residents in care. LPA observe during file reviews 3 out of 3 staff have not completed all of the required 20 hours of ongoing annual training.

85068.2(b) Needs and Service Plan. If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan…..***Based upon records reviewed, this requirement has not been met as evidenced by: Appraisal & Needs Service Plan for 5 out of 5 residend as of 04/01/2025 is not complete or signed by all partiesThis poses a potential Health and Safety risk to clients in care.

Document required staff training and orientation

87412 Personnel Records:(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not met as evidenced by: Based on records reviewed, Licensee did not have documentation of completed staff training. This poses a potential Health, Safetly or Personal Rights risk to residents in care.

Prompt responses to resident communications

87468.1 Personal Rights of Residents in All Facilities: (9) To have communications to the licensee from their representatives answered promptly and appropriately. This requirement is not met as evidenced by: Based on interviews conducted, Licensee did not promptly respond to resident representatives This poses a potential personal rights risk to residents in care.

87211 Reporting Requirements:(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by: Based on records reviewed Licensee did not follow regulation by not notifying the Department of a residents visit to the emergency room. This poses a potential Health, Safety or Personal rights risk to residents in care.

Assist residents with self-administered medication

87465 Incidental Medical and Dental Care:(4) The licensee shall assist residents with self-administered medications as needed.This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, Licensee did not ensure medications were administered as ordered. Resident did not receive eye drops as ordered and resident antibiotics were not given as ordered. This poses an immediate Health risk to residents in care.

Provide copies of signed agreements and amendments

87507 Admission Agreements:(e) The licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative, if any, immediately upon signing the admission agreement or modification. This requirement is not met as evidenced by: Based on interviews conducted, resident nor their representative received a copy of the admission agreement immediately after signing. This poses a potential Health, Safety or Personal rights risk to residents in care.

87405(d)(a) - (d)The administrator shall have the qualifications specified... (1) Knowledge of the requirements for providing care and supervision appropriate to the residents.This requirement is not met as evidenced by: inspection, the licensee diLPAs interviews, observations and records reviewed which show that Adminstrator has not been present a sufficent number of hours to properly meet the responsibilities of operating the facility. This is a potential risk to the health and safety of all residents in care.

Dispose of unused medications with required witness

87465(i) Incidental Medical and Dental Care (i) Prescription medications which are not taken.. upon termination of services..are otherwise to be disposed of shall be destroyed.This requirement is not met as evidenced by: Based on LPAs observation and discussion with Administrator that the facility did not destroy aprox 8 bags of medications that have been kept for aprox 4 months, poses/posed a potential health, safety or personal rights risk to persons in care.

87705(c)(5) Care Persons with Dementia - Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement was not met as evidenced by: during inspection of R1's records it was observed R1 did not have a Physician Repoprt & Admin informed it was taken out to be replaced with updated after visit that has been scheduled . This is a potential risk to the health and safety of residents in care

Document behavioral expression and related causes

87463(c) Reappraisals- (c)The licensee shall arrange a meeting with the resident, the resident’s representative... when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first... This requirement has not been met as evidenced by: Based on LPA file review showing that resident's care plans for 1 out of 4 resident (R1) were not been performed within last 12 months. This is a potential risk to the health and safety of residents in care.

Health screening and fitness requirements

87411(f)Personnel Requirements – General All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.This requirement is not met as evidenced by: Based on review of records, Staff S1 lack a health screening report, including TB test and results. 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.

Certified administrator requirements and substitute coverage

87405(a) Administrator – Qualifications and Duties. All facilities shall have a qualified and currently certified administrator. *** Based on statements and documents reviewed, this requirement has not been met as evidenced by: The facility’s Administrator Certificate expired on June 20, 2023 and the renewal application, submitted 2/26/2024, is in pending status. This poses an immediate risk to the health and safety of residents in care.

1569.618(c)(3) Employee Scheduling - Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement was not met as evidenced by: 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 5 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.

87705(c)(5) Care Persons with Dementia - Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement was not met as evidenced by: during inspection of R1's records it was observed R1 did not have a Physician Repoprt & Admin informed it was taken out to be replaced with updated after visit that has been scheduled . This is a potential risk to the health and safety of residents in care

1569.618(c)(3) Employee Scheduling - Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement was not met as evidenced by: 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 5 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.

Health screening and fitness requirements

87411(f)Personnel Requirements – General All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.This requirement is not met as evidenced by: Based on review of records, Staff S1 lack a health screening report, including TB test and results. 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.

Document behavioral expression and related causes

87463(c) Reappraisals- (c)The licensee shall arrange a meeting with the resident, the resident’s representative... when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first... This requirement has not been met as evidenced by: Based on LPA file review showing that resident's care plans for 1 out of 4 resident (R1) were not been performed within last 12 months. This is a potential risk to the health and safety of residents in care.

Dispose of unused medications with required witness

87465(i) Incidental Medical and Dental Care (i) Prescription medications which are not taken.. upon termination of services..are otherwise to be disposed of shall be destroyed.This requirement is not met as evidenced by: Based on LPAs observation and discussion with Administrator that the facility did not destroy aprox 8 bags of medications that have been kept for aprox 4 months, poses/posed a potential health, safety or personal rights risk to persons in care.

Ensure hazardous items are locked and not unattended

Based on observation, the licensee did not comply with the section cited above by having a disinfectant in an unlocked cabinet accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.