Mainplace Senior Living

Call 9-1-1 for imminent health threats

87465(g) Incidental Medical and Dental Care: (g) The licensee shall immediately telephone 9-1-1 if an injury... has resulted in an imminent threat to a resident’s health... including, but not limited to, an apparent life-threatening medical crisis... This requirement was not met as evidenced by: On 12/20/2024 at 4:10pm, R1 was found on their back on Memory Care patio from an unwitnessed fall. Hospice was called but did not arrive to assess R1 until 7pm. Hospice recommended facility call 911 at this time but were asked by the POA to allow POA to transport resident.

Care and supervision as defined by statute and rules

87464(f)(1) Basic Services: Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by: R1 suffered a total of six falls in the time span of approximately three months without documented re-evaluation of re-evaluation of care needs resulting in R1 being hospitalized 12/20/24 and diagnosed with left orbital floor fracture, maxillary sinus fracture and chronic dens C1 arch fracture.

First aid training requirements

Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.This requirement is not met as evidence by: The licensee did not comply with the section cited above in five of eight care staff files which poses a potenital safety risk to persons in care.

...20 hours, including six hours specific to dementia care... and four hours specific to postural supports, restricted health conditions, and hospice care.. before working... with residents.. remaining 20 hours... include six hours specific to dementia care and shall be completed within the first four weeks of employment...This requirement is not be as evidence by:Based on record review, the licensee did not comply with the section cited above in eight out of eight care staff files, which poses a potential health and safety risk to persons in care.

Reporting Requirements(a) Each licensee shall furnish...reports as the Department may require, including, but not limited to...(1) A written report shall be submitted to the licensing agency... within seven days of the occurrence of any of the events specified... below. This report shall include the resident’s name, age...disposition of the case.(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 being met as evidenced by the facilities failure to report the incident involving Resident 1 (R1) and Resident 2 (R2) which resulted in the police being called. This poses a potential health and safety risk to resident in care.

Dignity in personal relationships

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:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. The above requirement is not being met as evidenced by interview confirmation, document, and photo review that revealed Resident 1 (R1) sustained multiple bruises to upper body while in care. This poses a potential health and safety risk to residents in care.

Safe, healthful, comfortable accommodations

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:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. The above requirement is not being met as evidenced by interview confirmation and document review that reveal Resident 1 (R1) was being abused by Resident 2 (R2) while in care. This poses a health and safety risk to resident in care.

Personnel Records (1) training and orientation shall be documented: (A)...at least ten hours of initial training within the first four weeks of employment, and at least four hours of training annually thereafter...(B)For staff who provide direct care to residents with dementia...the licensee shall document ...orientation received as specified in Section 87707(a)(1)...in-service training received as specified in Section 87707(a)(2).This requirement is not met as evidence by: Based on LPA's observations and file reviews S1, S2 and S3 do not meet Tittle 22 training requirements.

Right to access and copy personal medical records

Per CCR Section 87468.2(a)(19) on Additional Personal Rights of Residents in Privately Operated Facilities, residents shall (...)"have prompt access to review all of their records (...). (...) records shall be provided within two (2) business days (...)." This requirement was not met as evidenced by: Based on records reviewed, facility records were not provided until more than two business days after a resident's authorized representative had requested them. This constitutes a potential risk to the health, safety and personal rights of residents in care.

Maintain separate complete record for each resident

Per the California Code of Regulations: "A separate, complete, and current record shall be maintained for each resident in the facility"This requirement was not met as evidenced by: Based on a review of written exchanges of facility staff with a resident's authorized representative, it was determined that at least one resident's admission agreement had been misplaced, hence rendering the resident's records incomplete at the time. This constitutes a potential risk to the health, safety and welfare of residents in care.

“Care and supervision” means the facility assumes responsibility for, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered.This requirement is not met as evidence by: Based on the facility’s own disclosure of events, they did not assume responsibility for Resident’s wandering behavior, resulting in multiple wanderings from the facility, which poses an immediate health and safety risk to persons in care.

Personnel Records (1) training and orientation shall be documented: (A)...at least ten hours of initial training within the first four weeks of employment, and at least four hours of training annually thereafter...(B)For staff who provide direct care to residents with dementia...the licensee shall document ...orientation received as specified in Section 87707(a)(1)...in-service training received as specified in Section 87707(a)(2).This requirement is not met as evidence by: Based on LPA's observations and file reviews S1, S2 and S3 do not meet Tittle 22 training requirements.

Theft and Loss (a) The licensee shall ensure… (i) Reports to the local law enforcement agency within 36 hours when… property with a then current value of one hundred dollars ($100) or more has been stolen. This requirement is not met as evidenced by: Based on interviews and LPA observations the facility did not report R1’s stolen property with a value of $400.00 to Law Enforcement within 36 hours as documented per facility’s Plan of Operation. This poses a potential risk to resident’s health and safety while in care.

Update reappraisal at required intervals

...appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate.. reappraisals shall document changes in the resident's physical, medical, mental, and social condition...This requirement is not met as evidence by; R1 sustained a fall on 6/10/23 at 6:30 a.m., 6/19/22 at 10:00 a.m., 6/20/22 at 12:10 p.m., 6/23/22 at 4:30 p.m., and on 6/28/22. R1 was not re-assesed and appraisal was not updated to reflect resident's change in condition, which poses an immediate health and safety risk to persons in care.

Document behavioral expression and related causes

...licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff... when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first...This requirement is not met as evidence by: R1 sustained a fall on 6/28/22 that required hospitalization, resulting in a significant change in R1's condition. A meeting was not arranged with R1, RP, or facility staff in regards to change of condition, which poses an immediate health and safety risk to persons in care.

eviction procedures.(c) The licensee shall, in addition to either serving the required thirty (30) days notice , sixty (60) days notice or seeking approval from the Department and service three (3) days notice on the resident, notify or mail a copy of the notice to quit to the resident's responsible person. This requirement is not met as evidenced by facility did not comply with proper eviction procedures which poses an immediate health, safety or personal rights risk to persons in care.

Maintenance and Operation. Facilities shall have signal systems which shall meet the following criteria...Operate from each resident's living unit. This requirement is not met as evidenced by: based on observation and interview the Licensee did not ensure the pull cord system was operable in room 334. This poses a potential risk to the health and safety of residents in care.

Maintain facility in clean, safe, sanitary condition

Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by: based on record review and interview the Licensee did not ensure the facility was kept clean and sanitary as documented in the narrative of this report. This poses a potential risk to the health and safety of residents in care.

Prompt responses to resident communications

Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To have communications to the licensee from their representatives answered promptly and appropriately. This requirement is not met as evidenced by: based on observation & interview the licensee did not ensure the facility phone is answered promptly. This poses a potential risk to the health & safety of residents in care.

Reporting Requirements. Each licensee shall furnish to the licensing agency such reports as the Department may require...the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence...events specified in (A) through (D) below. This requirement is not met as evidenced by: based on interview & record review the licensee did not notify R1's RP of the incident. This poses a potential risk to the health & safety of residents in care.

Maintain facility in clean, safe, sanitary condition

87303 Maintenance and Operation(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. This requirement is not met as evidence by; the facility's entire call button system is inoperable, which poses a potential health and safety risk to residents in care.

Maintain facility in clean, safe, sanitary condition

Maintenance and Operation-The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services.This requirement was not met as evidenced by: On 12/31/20, the cable at the building was nonoperational and was not repaired for 4 days. This poses a potential personal rights risk to residents in care.

Personal Accommodations and Services-Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident.This requirement was not met as evidenced by: According to Administrator Mike Marion, the dryers at the facility were nonoperational. Dryers were nonoperational on 12/2/21. residents were told by staff to take their laundry to a laundry mat to be washed and dried. Dryers were repaired by 12/4/20. This posed a potential health risk and personal rights risk to residents in care.