Senior's Retreat, Inc.

Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself...(5) Under no circumstances shall… postural supports include tying, depriving, or limiting the use of a resident's hands or feet. This requirement was not met as evidenced by: Based on witness and staff interviews a geri-chair was used to restrain a resident which poses a potential health and safety risk.

87464 (f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing... This requirement is not met (cont'd) as evidenced by: Based on LPA interviews one of four residents was in a soiled diaper for a period of time. This poses an immediate health and safety risk for residents in care.

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, employees and visitors. This requirement was not met as evidenced by S1 admitting to having issues with the facility heater heating the entire facility. S1 arranged for major repairs to the heating system January 18, 2025 and provided receipts.

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:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not being met as evidenced by S1 admitting to using a colostomy bag on the rectum/bottom area of Resident 1 to prevent loose stool from causing additional damage to the residents’ skin area that was already damaged and being treated.

87355 Criminal Record Clearance(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance… This requirement was not met as evidenced by:Based on an interview with S1, the licensee did not ensure ID1 was background cleared prior to working at the facility, which poses an immediate safety risk to persons in care.

(a) Residents in all residential care facilities... shall have all of the following personal rights:(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature... or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not being met as evidenced by R1 not being accepted back at the facility after being discharged by the hospital.

Based on staff interview and record review, the licensee did not comply with the section cited above, as two of two staff providing direct care and supervision do not hold a current, unexpired CPR and first aid training card, which poses a potential safety risk to persons in care.

Based on observation and AD interview, the licensee did not comply with the section cited above, as liability insurance for the facility is not being currently maintained, which poses a potential personal rights risk to persons in care.

Based on AD interview and staff record review, the licensee did not comply with the section cited above as staff training does not include 20 hours annually, eight hours of which shall be dementia care training, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, which poses a potential health, safety and personal rights risk to persons in care.

Based on AD interview and staff record review, the licensee did not comply with the section cited above, as staff did not complete 10 hours of initial training, consisting of 6 hours of hands-on shadowing training, and 4 hours of other training or instruction, which poses a potential health, safety and personal rights risk to persons in care.