Yorkshire Village

(j) The licensee shall evaluate staffing needs to ensure that there is a sufficient number of direct care staff, as specified in Section 87411, Personnel Requirements - General, to support each residents physical, social, emotional, safety and health care needs, as identified in their current appraisal. This requirement was not met as evidenced by: Observing staff schedule and interview with Executive Director. Staff was unable to redirect or prevent unnoticed elopement of R1. R1 Went unnoticed for over 2 hours.

(b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident. (1) Significant changes in condition, as defined in Section 87101, Definitions, include, but are not limited, to:(C)behavioral expression, as defined in Section 87101, Definitions, that may result in harm to self or others, such as unsafe wandering, elopement, hallucinations, lacking in hazard awareness, or lacking in impulse control. This requirement was not met as evidenced by: LPA also reviewed Unusual Incident/Injury Reports (LIC 624s) reporting R1's unwitnessed incidents occurring on 06/01/2024, 06/13/2024, 06/14/2024, and 06/17/2024 where R1 was reportedly found on the floor inside and outside of the facility. BOM Anguiano reported she was unable to find documentation of an updated reappraisal noting a plan to address R1's change of condition related to the unwitnessed incidents noted above. This poses a potential health/safety risk to residents in care.

(a)(3)Fires or explosions which occur in or on the premises shall be reported immediately to the local fire authority; in areas not having organized fire services, within 24 hours to the State Fire Marshal; and no later than the next working day to the licensing agency. This was not met with evidence by: Facility staff did not report fire evacuation in Building B's of the (42) forty-two residents the next working day as required. The facility submitted an incident report of the fire evacuation of Building B's for (42) forty-two residents on 3/17/2025.

87464 Basic Services: (f) Basic services shall at a minimum include:(6) Arrangements to meet health needs,...This requirement is not met as evidence by: Based on medication review and documents reviewed licensee did not ensure medications for R1,R2,R4,R6,R7,R8,R9 were available at the facility for the residents which poses an immediate risk to the health, safety, or personal rights of the persons in care.

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(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 in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case (D)Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.This requirement is not met as evidenced by: Based on records review, Licensee only reported to the Department 2 out of 23 incidents that occurred with R1, which poses a potential health and safety risk to 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 provisions 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 interviews and records review, the licensee did not comply with the section cited above when they were aware of the disrepair of R1’s floor at least two months before 08/02/2023, but did not repair the floor, which posed an immediate health and safety risk to residents in care.

87463 Reappraisals(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above when they did not complete a reappraisal of R1 following R1’s hospitalizations for falls on 06/25/2021 and 03/19/2023, which posed a potential health and safety risk to residents in care

Personal Rights of Residents in All Facilities: (a) Residents in all RCFEs shall have all of the following...rights: (8) To have their representatives regularly informed by the licensee of activities related to care or services...This requirement was not met, as evidenced by: Based on interviews, the licensee did not ensure R1's right to have their representative informed of activities related to care was met. Admin. revealed the responsible party of R1 wasn't notified due to R1 receiving services from a hospice agency, who would have reached out to the responsible party for notification.

87411 Personnel Requirements- General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not ensure facility personnel to be sufficient in numbers and competent to provide the services necessary to meet resident needs.

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:(11) To have their visitors....permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This requirement was not being met as evidenced by: Based on interviews obtained, it was determined that this poses a potential health and safety risk to residents in care.