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Inspection visit

complaint

GRACE RETIREMENT VILLAGELicense 3060900491 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

did not match. On May 31, 2023, R1 was hospitalized after an unwitnessed fall. R1 was hospitalized at St. Jude Medical Center and was admitted for severe sepsis. At the time of being admitted, hospital staff observed R1 with multiple burns and skin tears across the upper and lower body. Staff interviewed denied observing burns and stated the burns were carpet burns. Pictures taken by hospital staff depict skin tears and burns resulting in blisters over R1’s extremities including arms, fingers and legs. When shown the pictures, Staff 1 (S1) advised investigators carpet burns don’t blister. Hospital records diagnose R1 with a history of dementia but are unclear where/how they came to know R1 had a history of dementia. Emergency Medical Technicians (EMTs) reported R1’s records were unavailable upon arriving to the facility as records were locked inaccessible to staff. EMT personnel interviewed recalled speaking with their partner and saying the arm injury observed on R1 was “definitely not a skin tear” as reported by staff. The responder recalled seeing the resident’s arm as having some sort of burn but could not recall if it was or was not wrapped upon arrival. Although it remains unclear exactly how the resident sustained the injuries, it is clear the injuries sustained occurred while in care at the facility and contributed to the R1’s hospitalization. The facility is being cited per Title 22, Division 6 of the California Code of Regulations. A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f) An exit interview was conducted, and a copy of this report, 9099-D Page, and Appeal Rights was left at the facility.

Citations

4 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87405(a)Type B

    Administrator Qualifications and Duties. …When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section… This regulation was not met as evidenced by: Licensee failed to have a qualified designated substitute when Administrator was not in the facility on 8/24/23 as evidenced by Department staff observations and comments made by Administrator. This poses a potential risk to residents health and safety while in care.

  • 87464(f)(1)Type A

    87464(f)(1) Basic Services. Basic services shall at a minimum include: Care and supervision…This requirement was not met as evidence by: Licensee failed to ensure R1 was receiving care and supervision which resulted in R1 sustaining a burn from an unknown cause while in the care of the facility as evidence by interviews conducted and hospital records reviewed. This poses an immediate health and safety risk to residents in care.

  • 87469(c)(1)Type B

    Advanced Directives and Requests Regarding Resuscitative Measures. Immediately telephone 9-1-1, present the advance directive and/or request regarding resuscitative measures form to the responding emergency medical personnel… This regulation was not met as evidenced by: Licensee failed to ensure records were made available to emergency personnel as evidenced by records being locked inaccessible to staff. This poses a potential risk to resident’s health and safety while in care.

  • 87755(b)Type B

    Inspection Authority of the Licensing Agency. The licensee shall ensure that provisions are made for private interviews with any resident or any staff member... This regulation was not met as evidenced by: Licensee failed to ensure provisions were made for private interviews with staff on 8/24/23 as evidenced by Administrator’s statements. This poses a potential risk to residents’ personal rights and safety while in care.

FAQ · About this visit

Common questions about this visit

What happened during the December 20, 2023 inspection of GRACE RETIREMENT VILLAGE?

This was a complaint inspection of GRACE RETIREMENT VILLAGE on December 20, 2023. 1 citation were issued: 1 Type A (serious).

Were any citations issued to GRACE RETIREMENT VILLAGE on December 20, 2023?

Yes, 1 citation was issued (1 Type A, 0 Type B). The first citation was for: "Administrator Qualifications and Duties. …When the administrator is not in the facility, there shall be coverage by a de..."

What type of inspection was this?

This was a complaint inspection. Complaint inspections are triggered when someone reports a concern about the facility to CCLD.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.