Country Club Manor

80075 Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.This requirement was not met as evidenced by: Record review and interview and observation by the LPA, where 3 of 5 records requested at random had incomplete or unusable documentation, 1 unusable reasoning of refused medication and 2 missing PRN reasoning. This posed a potential risk to the health, safety or personal rights of the clients in care.

1569.2 Definitions - (c) “Care and supervision” means the facility assumes responsibility for...ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. The above requirement was not met as evidenced by:Based on a review of records, R2 had a history of aggressive behavior. Based on interviews, residents in the dining room were left unsupervised. This posed an immediate risk to the health, safety and personal rights of residents in care.

Reporting Requirements(a) Each licensee shall furnish...the following: (1) A written report to the licensing agency and to the person responsible for the resident...(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. The above requirement was not met as evidenced by:Based on interviews with S2, S3, and S5, the responsible party for R1 was not notified of the incident with R2. This posed a potential threat to the health, safety, and personal rights of the residents in care.

Safe, healthful, comfortable accommodations

Personal Rights of Residents in All Facilities - (a) Residents...shall have following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.The above requirement was not met as evidenced by: Based on a review of records, as well as through interviews with K1, K2, and R3, R1 was attacked on 07/24/24, 08/04/24, and R3 was struck on 08/04/24 as well. This posed an immediate risk to the health, safety, and personal rights of the residents in care.

Document behavioral expression and related causes

87463(c) Reappraisals(c) The licensee shall arrange a meeting with the resident, the resident’s representative...when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. The facility did not comply with the above requirement as evidenced by a records review showing that R2's LIC 602 was dated 09/21/22. R2 had a listed diagnosis of dementia in her medical reports and a reappraisal should have been done by 09/21/23.

Prohibit false or misleading facility statements

87207 False ClaimsNo licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. The facility did not comply with the above requirement as evidenced by the fact that their documentation (LIC 624) indicated that the responsible party and the primary care physician of R1 had been notified and they had not. This posed a posed a potential threat to the Health, Safety, and Personal Rights of residents in care.

Safe, healthful, comfortable accommodations

Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This facility was found to be deficient as evidenced by the presence of facility residents who infringed on the personal rights of nearby residents on a daily basis making them uncomfortable in their living spaces and environment. This posed an immediate threat to the Health, Safety, and Personal Rights of residents in care.

Certified administrator requirements and substitute coverage

87405(a) Administrator - Qualifications and Duties(a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours…This requirement is not met as evidenced by: Based on interviews, records review and observations, the licensee did not comply with the section cited above. The administrator did not ensure that administrator is at the facility for sufficient number of hours, which poses/posed a potential health, safety or personal rights to person in care.

87555(b)(1) General Food Service Requirements(b) The following food service requirements shall apply:(1) Where all food is provided by the facility arrangements shall be made so that each resident has available at least three meals per day. Exceptions may be allowed on weekends and holidays providing the total daily food needs are met. Not more than fifteen (15) hours shall elapse between the third and first meal.This requirement is not met as evidenced by: Based on interviews and records review the administrator did not comply with the section cited above. The licensee did not ensure that resident is provided with three meals per day. Meal logs reviewed reveals discrepancies; therefore, it is unclear if residents received their meals.

Notify agency before locking doors or gates

87705 Care of Persons with Dementia. (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).This requirement is not met as evidence by: Based on interviews and records review, the licensee did not comply with the regulation cited above. LPA observed knives were not stored inaccessible to residents which poses an immediate health and safety risk to residents in care.

Ensure hazardous items are locked and not unattended

87309 Storage Space(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients This requirements was not met as evidenced by observation by Staff and LPA also by checking the unlocked cart. This poses an immediate health and safety risk to residents in care.

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...(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not as evidenced by: Licensee did not ensure a proper medication order was followed for R1. This posed an immediate health and safety risk to resident in care.

87224(b) Eviction ProceduresThe licensee may, upon obtaining prior written approval from the licensing agency, evict the resident upon three (3) days written notice to quit. The licensing agency may grant approval for the eviction upon a finding of good cause...This requirement was not as evidenced by: Based on observation and record review, the Licensee did not ensure that the 3-day eviction notice was properly given to the resident. Licensing did not grant written approval prior to Licensee giving out 3-day eviction notice to Resident 1. This poses a potential health/safety risk to residents in care.

Maintenance and OperationFacilities shall have signal systems which shall meet the following criteria:(1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall:(A) Operate from each resident's living unit. This requirement was not met as evidenced by: Based on observation and interview this facility did not maintain compliance as evidenced by the call button in R1's room 143 not in proper functioning order. This poses a potential threat to the Health, Safety, and Personal Rights of all residents in care.

Care of Persons with Dementia 87705(l)(6)(l)The following initial and continuing requirements shall be met for the licensee to 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 was requirement was not met as evidenced by: Based on interview and record review, Licensee did not enure resident was properly supervised. R1 sustained a fall with no supervision around. The cook who witnessed the fall just so happened to be outside at the time. This poses an immediate health, safety, and personal rights risk to persons in care.

Limit staff assistance with self-administered drugs

Incidental Medical and Dental Care(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 was not met as evidenced by unsigned medication administration dates for prescribed routine medications in December 2020 and January 2021 for R1. This poses an immediate threat to the health and safety of residents in care.

Provide resident hot water for personal care

Based on LPAs testing of water temperatures in rooms 6 and 152, LPA recorded temperatures of 93.5 degrees and 130 degrees F respectively the licensee did not comply with the section cited above in as the water temperature was not inside the approved approved varience of 105 to 120 degrees F which poses an immediate health, safety or personal rights risk to persons in care.

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: (14) To have reasonable access to telephones, to both make and receive confidential calls. The licensee may require reimbursement for long distance calls. This requirement was not met as evidenced by: interviews. The licensee failed to comply with the regulation referenced above. The facility does not have a phone in a common area for residents to make or receive confidential calls. This poses a potential health, safety, and/or personal rights risk to residents in care.