Almond Heights

87465 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 is not met as evidenced by: Based on incident report and staff interview the facility did not provide resident, R1 their medications as prescribed which poses an immediate health and safety risk to residents in care.

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 record review and interviews, it was concluded that resident, R1 was able to AWOL from the facility, unassisted on 09/12/25 , which poses an immediate risk to the health and safety of residents in care.

80075 -Health Related Services (b)(5)(B) - Once ordered by the physician the medication is given according to the physician's directions.... This requirement was not met as evidenced by: Based on record review from the facility, it was observed that on 09/19/24, resident, R1 was given medications, Calcium Citrate 250mg- 2 tablets, Simvastatin 20mg-1 tablet and Memantine 10 mg- 1 tablet by mistake from staff and these medications were not ordered by R1s physician which poses an immediate health and safety risk to residents in care.

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 evidence by; Record review and interviews conducted indicated that staff assisted R1 to their bed on 04/18/24 without their consent which poses an immediate risk to the health and safety of residents in care.

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 records of the incidents for R2, it was concluded that R2 was able AWOL from the facility unassisted on 05/08/24 which poses an immediate risk to the health and safety of residents 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.. this requirement is not met as evidence by; Record review and gathered information indicated that facility does not have updated Medical Assesment (LIC602) and Re-appriasal completed for R1 as required which poses a potenial risk to health and safety for residents in care.

87211-Reporting Requirements(a) (D)- (a) Each licensee shall furnish to the licensing agency such reports as the Department….(D) Any incident which threatens the welfare, safety or health of any resident,…… unexplained absence of any resident…..This requirement is not met as evidenced by; Based on records review,it has been observed that facility did not report R1 and R2s AWOL incident for 02/26/24 to department as required which poses potential health and safety risks for residents in care.

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 information of the incident for R1 and R2, R1 and R2, AWOL from the facility on 02/26/24. This poses a immediate risk to the health and safety of residents in care.

Based on record review and interviews it has been concluded that facility does not have Personnel form (LIC 501) for 3 staff out of 10, first aid and CPR certification for 3 out of 10 staff, and Health Screening/TB for 2 out of 10 staff files, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observatios and staff interviews for medication audit, LPA learned that R1 and R2 have medications in their rooms and they have dementia diagnosis and cannot manage their medications per physicians orders, which poses an immediate health, safety or personal rights risk to persons in care.

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 records of the incidents for R1,R1 AWOL from the facility on 10/12/23 and on 11/01/23. This poses a immediate risk to the health and safety of residents in care.

87211-Reporting Requirements(a) (D)- (a) Each licensee shall furnish to the licensing agency such reports as the Department….(D) Any incident which threatens the welfare, safety or health of any resident,…… unexplained absence of any resident…..This requirement is not met as evidenced by; Based on records review,it has been observed that facility did not report R1s AWOL incident for 11/01/23 to department as required which poses potential health and safety risks for residents in care.

87506-Resident Records- (d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours…this requirement is not met as evidenced by; Facility did not provide requested documents to department related to resident, R1s elopement incident which were requested on 10/23/23,10/25/23 and 10/30/23 which poses a potential health and safety risks for residents in care.

87464-Basic Services-(f)Basic services shall at a minimum include:(1)Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not as evidence by…. Based on record review and interviews, it has been concluded that facility did not provide proper care and supervision for R1 in which R1 sustained a fall on 02/14/2023 resulting in a fractured neck which poses an immediate health and safety risk for residents in care.

80075 Health Related Services (b)(5)(B) - Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by: Based on record review from the facility, on 06/04/23, R1 was given medications, Fenofibrate 54mg- 1 tablet, and Fluoxetine 10 mg- 1 tablet by mistake from staff and these medications were not ordered by R1s physician which poses an immediate health and safety risk to residents in care.

Incidental Medical and Dental Care (a)(3) When residents require prosthetic devices, vision and hearing aids, the staff shall be familiar with the use of these devices and shall assist such persons with their utilization as needed. This requirement was not met based on statements and records that R1's for a time did not require all of the assistance needed to manage their hearing aid.

** amended** Incidental Medical and Dental Care (a) (4) The licensee shall assist residents with self-administered medications as needed.This requirement was not met as evidenced by records and interviews that found R1 and R1 did not received medications as prescribed and orders by their physicians.This posed an immediate health risk to residents.

87211 Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports as the Department [...]: (1) A written report shall be submitted 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 [...] This requirement was not met as evidenced by: interviews and documentation reviewed. The licensee did not comply with the section cited above by not reporting incidents which threatened the welfare of R1. This poses a potential health, safety, and/or personal rights risk to residents in care.