Meadow Oaks of Roseville

Arrange appropriate medical and dental care

Incidental Medical and Dental Care(a) (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.This requirement was not met based on written report and interview.This posed a potential risk to the resident.

Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met based on records and statements which found R1 received a disconitnued medication.This posed a potential risk to R1.

Assist residents with self-administered medication

Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met based on records and statements.This posed a potential risk to R1.

Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(4) There is an adequate number of direct care staff to support each resident’s ... safety ...needs as identified in his/her current appraisal and demonstrated behaviors This requirement was not met based on records and interviews that found adequate number of staff were not present to implement R1's care need. This posed an immediate risk to R1.

Advanced Directives and Requests Regarding Resuscitative Measures (c)(3)(c) (3) Specifically for a terminally ill For emergencies not directly related to the expected course of the resident’s terminal illness, the facility staff shall immediately telephone emergency response (9-1-1). This requirement was not met met based on records review and statements that found resident with an unwitessed fall did not receive emergency response. This posed an immediate risk to the resident.

Regular observation and documentation of resident changes

The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning …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…This requirement was not met based on records and interviews which showed a change of condition not brought to the physician’s attention. This posed an immediate risk to the resident.

Review and revise record after changes

Based on record review the licensee did not comply with the section cited above in 3 of 6 records resident appraisals were not signed as reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.

Right to sufficient care and qualified staff

Additional Personal Rights of Residents in Privately Operated Facilities(a) In addition to the rights listed in Section 87468.1, ...elderly shall have all of the following personal rights:(4) 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 was not met as evidenced by statements and records showing lack of supervision at the time of R1’s fall on 5/2/24. This posed an immediate risk to R1.

Maintain facility in clean, safe, sanitary condition

87303 Maintenance and Operation (a) The facility shall be … safe, … 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 was not met based on observations which found surface from walkway to landscaping presented an uneven surface for un unsteady, unsupervised resident to fall. This poses a potential risk to residents.

Report specified resident events within seven days

87211 Reporting Requirements(a)(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified (D) Any incident which threatens the welfare, safety or health of any resident… This requirement was not met based on interviews and records which found unreported incidents of elopements by R1. This posed a potential risk to resident.

Administrator - Qualifications and Duties(h) (5) Provide or ensure the provision of services to the residents with appropriate regard for the residents' physical and mental well-being and needs, including those services identified… This requirement was not met based on interviews and records that found R1's supervision regularly did not receive the services of ambulation supervision, staff were unaware of when 9-1-1 was to be called and Admin was unaware of a significant event in the facility. This posed an immediate risk to the resident

Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(4) There is an adequate number of direct care staff to support each resident’s ... safety ...needs as identified in his/her current appraisal. This requirement was not met based on records and interviews that found adequate number of staff were not present to implement R2's identified care need. This posed an immediate risk to R2.

Incidental medical and dental care services

Incidental Medical and Dental Care (a) A plan for incidental medical and dental care ... The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self- administered medications as needed. This requirement was not met based on records and interviews which found care staff were not compliant with assisting R1 correctly with medications. This posed an immediate risk to R1.

Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and current appraisal health care needs as identified in his/her.. This requirement was not met based on reports and statements. This posed an immediate risk to R1's health and safety.

Incidental Medical and Dental Care (a)(5)(D) Assistance with self-administration does not include forcing a resident to take medication,... 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 on 6/4/24 when R1 was forced to take medications by two caregivers and a med tech.This posed an immedicate risk to the resident.

Report suspected non-serious physical abuse within 24 hours

Reporting requirements- (c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1). This requirement was not met by S1 or S2 who witnessed the incident of 6/4/24 and failed to report to police within 24 hours. This posed an immediate risk ro residents.

Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and current appraisal health care needs as identified in his/her.. This requirement was not met based on reports and statements. This posed an immediate risk to R1's health and safety.

Comply with all admission agreement terms

87507(f) Admission AgreementThe licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement was not met as evidenced by: Based on documentation review, Licensee did not adhere to admission agreement and did not provide refund to R1’s RP. This poses a potential potential health and safety risk to resident in care.

Maintain cleanliness and prevent incontinence odors

87625 Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:(3) Ensuring that incontinent residents are kept clean and dry, and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by: Based on interviews and observation the licensee did not ensure R1’s room is free of odor which poses a potential health and safety risk to resident in care.

Protection from punishment and intimidation

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: (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 is not met as evidenced by: Based on interview the licensee did not ensure that resident was afforded their personal rights which poses an immediate health and safety risk to residents in care.

Dignity in personal relationships

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: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on interviews conducted facility did not ensure staff were trained on how to treat resident with dignity and respect. Resulting in S1 grabbing/twisting R1's arm.

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, LPA observed hallway light bulbs and bathroom light bulbs located in the Memory Care unit were out and not working. This poses a potential health and safety risk to residents in care.

Limit staff assistance with self-administered drugs

87465(a)(5) Incidental Medical and Dental Care Services (a) A plan for incidental medical and dental care shall be developed by each facility. (5) the licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on records review and interviews, medication was not given to R1 and not documented on the Medication Administration Records per facility policy.

Regular representative updates on care

87468.1 (a)(8) 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: (8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. This requirement is not met as evidenced by: Based on records review and interviews, facility did not notify the change in physician’s order.