Caleo Bay Alzheimer's Special Care Center

(f) Licensees that lock exterior doors or perimeter fence gates…(6) Locked exterior doors or perimeter fences with locked gates shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents. This requirement was not met as evidenced by: Based on interviews and records review, R1 eloped from the facility locked perimeter. This poses a potential health, safety, or personal rights risk to residents in care.

Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in S1,S2, S3, S4, S5, S6, S7 did not have a health screening in their personnel file which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in employee rights for S1, S2, S3, S4, S5, S7, S8, S9, S10, criminal record statement for S1, S6, personnel record or job appliation for S3, S9 not observed in personnel files which poses/posed a potential health, safety or personal rights risk to persons in care.

(a) In addition…all of the following personal rights:(8) To be free from neglect…physical, or sexual abuse.This requirement was not met as evidenced by: Based on interviews and records review,S1 was neglectful while changing R1, by pushing R1 and falling on top of R1’s leg resulting in a fracture. This poses an immediate health, safety or personal rights risk to residents in care.

(a) Each licensee shall furnish...(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...This requirment was not met as evidenced by: Based on interviews and records review it was found incident for R1 was reported past 7 days and reported inaccurate occurence to responsible party. This poses an potential health saftey or personal rights risk to residents in care.

(a) A plan for incidental medical...care shall be developed...(1)The licensee shall arrange, or assist in arranging, for medical...care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Based on interviews and records reviews, R1 did not receive appropriate medical attention for fractured until (3) days after. This was due to S1 disseminating inaccurate statements. This poses an immediate health, safety or personal rights risk to residents in care.

(e) All individuals subject to a criminal record review...shall prior to working...in a licensed facility:(2)Request a transfer of a criminal record clearance...This requirment was not met as evidenced by: Based on record review it was found that three staff were not associated to the facility. This poses an immediate health safety or personal rights risk to residents in care.

Based on observation, interview, and record review, the licensee did not comply with the section cited above in having five (5) staff members associated with this facility during the time of LPA's visit which poses an immediate health, safety or personal rights risk to persons in care.

Maintenance and Operation: (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care... shall deliver hot water. Hot water temperature controls shall be...a temperature of not less than 105 degree F... This requirement was not met by: Based on observations, the Licensee did not comply with the above regulation with at least two resident bathrooms (#46 & #36). LPA Colvin observed a maximum hot water tempurature in Room #46 of 92.6 degrees, and 86.7 degrees in Room #36. This is a potential health risk for residents in care.

Additional Personal Rights of Residents in ...Facilities: (20) To be protected from involuntary transfers, discharges, and evictions. A licensee shall not involuntarily transfer or evict residents...and shall comply with all eviction and relocation protections for residents.... This requirement was not met by: Based on record review, the Licensee did not comply with the above regulation with one resident (R1). Administrator provided R1's family with an eviction notice on 9/14/22 which was effective immediately. The facility also did not conduct a reassessment of R1. This is an immediate personal rights violation of R1.

Personnel Requirements - General: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not being met as evidenced by: On October 26, 2019 R1 was observed with a bloody face and injuries to eye and lip. Staff interviews could not provide evidence as to how R1 sustained the injuries. This posed an immediate health and safety risk to resident in care.

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 being met as evidenced by: Based on interviews and record reviews, between January 1, 2019 and October 26, 2019, R1 sustained multiple falls. Licensee did not ensure staff had been sufficiently informed of R1’s fall risk and/or what precautions were to be used to mitigate further falls. This posed a potential health and safety risk to resident in care.