Summerfield of Roseville

Regular observation and documentation of resident changes

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. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met based on facility failed to reassess R1 after resident sustained multiple falls. R1 sustained 9 falls between 03/12/24 and 01/14/25. This posed an immediate Health and Safety risk to residents in care.

Based on interview and records review 3 out of 5 residents did not have updated physician's report in their files which poses/posed a potential health, safety or personal rights risk to persons in care.

Maintain required personnel records for staff

Based on record reviewed, LPA observed that health screening and TB is missing 1 out of 5 files, and 5 out of 5 were missing a job application, which poses/posed a potential health, safety or personal rights risk to persons in care.

Give PRN medication by physician order

Incidental Medical and Dental Care (c ) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication ... requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Based on observation, the facility did not ensure medication was given according to physician directions. During the review of medications, the LPA foundthat for R1’s medications were found to be full and not given to R1.

87705 Care of Persons with Dementia (c) 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 is not met as evidenced by: Based on records review, the facility did not comply with he section cited. R1 did not have updated medication assessment which poses a potential health, safety, or personal rights risk to person in care

This requirement is not met as evidenced by: Based on interview and records review 2 out of 5 residents did not have updated physician's report in their files which poses/posed a potential health, safety or personal rights risk to persons in care.

Protection from punishment and intimidation

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: (3)To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met as evidenced by: Based on interviews and documentation reviewed, R1 refused medication twice and three (3) facility staff restrained R1 physicially when assisting with medication. This poses an immediate health and safety risk to resident in care.

§1569.69 Employees assisting residents with self-administration of medication; training requirements. (a) Each residential care facility ... the employee shall complete 16 hours of initial training. This training shall consist of eight hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and eight hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. Based on interviews, facility does not have records of S3's medication training or credentials. This poses an immediate health and safety ricks to resident in care.

87465(a)(5)(D) Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed... include forcing a resident to take medication, hiding or camouflaging medications in other substances without the resident's knowledge and consent, or otherwise infringing upon a resident's right to refuse to take a medication. This requirement was not met as evidenced by: Based on interviews and documentation reviewed, R1 refused medication twice and facility staff had physically restrained R1 and insisted for R1 to take medication. This poses an immediate health and safety ricks to resident 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, employees and visitors. This requirement is not met as evidenced by: Based on observation the licensee did not ensure that facility kitchen is free from mold which poses an immediate health and safety risk to residents in care. LPA also observed kitchen equipment such as ice machine, mixer, and oven to be in disrepair.