Legacy Lane Senior Living Ii

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Based on LPA's observations and records reviewed, the facility did not ensure that residents' medications were kept in a safe and locked place, which poses an immediate health, safety, and personal rights risk to the residents in care.

§1569.625 Staff training; legislative findings; contents (b)(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. This requirement is not met as evidenced by: Based on LPA's observations and records reviewed, the facility did not ensure that staff on site received training in accordance with the Health and Safety code, which poses a potential health, safety, and personal rights risk to the residents in care.

87507 Admission Agreements (h) The admission agreement shall not contain the following: (4) Any provision that violates the rights of any residents including but not limited to those specified in Section 87468 and in Health and Safety Code section 1569 et seq. This requirement is not met as evidenced by: Based on records reviewed, the facility did not ensure that admission agreements for the residents did not violate rights indicated in Health and Safety Code section §1569.652(c), which poses a potential health, safety, and personal rights risk to the 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. (...) The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by: Based on observations, interviews conducted, and records reviewed, the facility did not ensure to provide sufficient staffing to meet the needs of the residents in care, which poses a potential health, safety, and personal rights risk to the residents in care.

87628 Diabetes (a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional. This requirement is not met as evidenced by: Based on LPA's observations, interviews conducted, and records reviewed, the facility did not ensure resident admitted was assessed to be able to perform their own glucose testing, which poses a potential health, safety, and personal rights risk to the residents in care.

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year (...). This requirement is not met as evidenced by: Based on LPA's observations and records reviewed, the facility did not ensure to maintain a record of centrally stored medications for each resident for at least one (1) year, which poses an immediate health, safety, and personal rights risk to the residents in care.

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: Based on interviews conducted and observations, the facility did not ensure that residents' medications were kept in a safe and locked place, which poses an immediate health, safety, and personal rights risk to the residents in care.

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Based on interviews conducted and observations, the facility did not ensure that residents' medications were kept in a safe and locked place, which poses an immediate health, safety, and personal rights risk to the residents in care.

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Based on LPA's observations and records reviewed, the facility did not ensure to make complete and current records available to licensing agency staff to review, which poses an immediate health, safety, and/or personal rights violation to the residents in care.

87411 Personnel Requirements - General (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (4) Knowledge required to safely assist with prescribed medications which are self-administered. This requirement is not met as evidenced by: Based on LPA's observations, interviews conducted, and records reviewed, the facility did not ensure that staff assisting residents with self-administered medication had medication training at the facility, which poses an immediate health, safety, and/or personal rights violation to the residents in care.

87405 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 to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This requirement is not met as evidenced by: Based on LPA's observations and records reviewed, the facility did not ensure to have an assigned certified administrator at the facility, which poses a potential health, safety, and/or personal rights risk to the residents in care.

Based on LPAs' observations, the facility did not insure that hot water was not less than 105 degrees F and not more than 120 degrees F when hot water was measured at 155 degrees F, which poses an immediate health, safety, or personal rights violation to the residents in care.

Based on LPAs' observations and records reviewed, the facility did not insure to document quarterly drill logs in accordance with the Health and Safety code, which poses a potential health, safety, or personal rights violation to the residents in care.

Based on LPAs' observations, the facility did not insure to have a complete first aid kit maintained on the premises, which poses a potential health, safety, or personal rights violation to the 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 evidenced by: Based on interviews conducted and records reviewed, the facility did not ensure that residents were treated with dignity and respect in their relationships with other residents, which poses a potential health, safety, and personal rights risk to residents in care.

Based on LPA's observations, the facility did not ensure that the kitchen area was free from insects, which poses a potential health, safety, and personal rights risk to residents in care.

87555 General Food Service Requirements (b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by: Based on observations and interviews conducted, the facility did not ensure that the kitchen area was free from insects, which poses a potential health, safety, and personal rights risk to residents in care.