New Horizons

87468.2(a)(4)Additional Personal Rights of Residents in Privately Operated Facilities(4) To care, supervision, and services. meet their individual needs.. delivered by staff.. sufficient in numbers, qualifications.. to meet their needs.This requirement is not met as evidenced by: Based upon review of facility, records, observations, and interviews licensee failed to ensure that R1 was provided with care, supervision,services required. As a result, R1 sustained a fracture while at facility. This violation posed an immediate health and safety risk to residents in care.

87411 Personnel Requirements - General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) orThis requirement is not met as eveidenced by: Based on observation, interview, record review, the licensee did not comply with the section cited above by not transferring Staff #10 (S10) criminal backgound clearance to the facility prior to employment which pose potential health, safety and personal rights risks to residents in care.

87465 Incidental & Medical Services (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...(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Based on observation, interview, record review, the licensee did not comply with the section cited above by not updating Resident #1 (R1) Medication Administration Record (MAR) when dispensing R1 medications from 07/01/2024 to 07/15/2024 which poses an immediate health, safety or personal rights risk to persons in care.

87608 Postural Supports (a) Based on the individuals preadmission appraisal....(3) A written order from a physician indicating the need for the postural support shall be maintained in the residents record. The licensing agency...This requirement is not met as evidenced by: Based on observation, interview and record review, the licensee did not comply with the section cited above by having Resident #2 (R2), Resident #3 (R3), Resident #4 (R4), Resident #8 (R8), Resident #9 (R9), Resident #10 (R10) with half bed rails with no written order from their physician indicating the need for the postural support for mobility which poses a potential health, safety and personal rights risks to resident in care.

87608 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...(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Based on observation, interview, record review, the licensee did not comply with the section cited above by having a full bed rail for Resident #1 (R1) and R1's not on hospice and no exception was submitted and approved to CCLD which poses an immediate health, safety or personal rights risk to persons in care.

87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by: Based on observation, interview, record review, the licensee did not comply with the section cited aboveby not having a completed Physician Report with Physician Signature Date for Resident #1 (R1) which poses an immeidate health, safety or personal rights risk to persons in care.

87411 Personnel Requirements - General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) orThis requirement is not met as eveidenced by: Based on observation, interview, record review, the licensee did not comply with the section cited above by not transferring Staff #8 (S8) and Staff #9 (S9) criminal backgound clearance to the facility prior to employment which pose potential health, safety and personal rights risks to residents in care.

Based on interview and observation, the licensee did not comply with the section cited above evidenced by not having auditory devices on the facility exits which poses a potential health, safety, or personal rights risk to persons in care.

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. Based on interview and document review, the licensee did not comply with the section cited above evidenced by not completing an annual medical assessment and reappraisal for Resident R1 which poses an immediate health, safety, or personal rights risk to persons in care.