Eskaton Gold River Lodge

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 was not met as evidence by: Based on interviews and record review, Licensee did not ensure a dignified relation between a staff member and resident in care regarding care procedures. This posed a potential health, safety, and resident rights risk to residents in care.

Additional Personal Rights of Residents in Privately Operated Facilities(20) To be protected from involuntary transfers, discharges, and evictions...The Licensee did not meet the above requirement when: Based on a review of records and interviews, on 11/19/24, the RCC did not allow R1 to return to the facility when the hospital tried to discharge R1 so R1 could return home. This posed an immediate risk to the health, safety, and personal rights of residents in care.

Observation of the ResidentThe licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional... appropriate assistance is provided...The Licensee did not meet the above requirement when: Based on a review of records and interviews, staff became aware of R1 having a change in condition on 11/5/2024 and staff did not contact R1’s (PCP) when the change of condition was noted. This posed an immediate threat to the health, safety and personal rights of residents in care.

Based on observation, the licensee did not comply with the section cited above in 2 of 4 rooms inspected which poses an immediate health, safety or personal rights risk to persons in care.

Infection Control Rqmts. 87470(b)(2)(b) In addition to ...with a contagious...(2) All staff ...Personal Protective Equipment (PPE) to prevent exposure to infectious agents...The licensee did not ensure the above regulation was enforced as evidenced by: Based on interviews with S2 and S3 along with this LPA's observations on 11/14/25, 3 staff members were not following the infection control protocol and were not wearing masks/PPE. This posed a potential threat to the health, safety, and/or personal rights of residents in care.

Administrator Qualifications(b) The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee.This requirement was not met as evidenced by: Based on interviews and records review, the Administrator did not ensure that the COVID-19 Preparedness and Response Plan was implemented. Residents were not tested upon move-in, additional testing was not conducted immediately on those who were in proximity of infected residents, and staff did not wear masks in communal areas. This posed an immediate risk to the heath, safety, and personal rights of residents in care.

Incidental Medical and Dental(a) ... incidental medical and dental care shall be developed by each facility... provide for assistance in obtaining such care ...(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by:Based on interviews and a review of records, R1 was denied medical assistance when they requested a COVID test. This posed an immediate risk to the health, safety and personal rights of residents in care.

General Food Service-The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service.This was not met as evidenced by: Based on interviews, food was not being served at the appropriate temperature due to equipment malfunction, the placement of a fan over the hood in the kitchen, and staff not being trained to pace meals. This posed a potential threat to the health, safety and/or personal rights to residents in care.

(d) All personnel shall be given on the job training... provide knowledge of and skill in the following...as evidenced by safe and effective job performance: (3) ... to provide necessary resident care and supervision... The facility did not meet the above requirement as evidenced by: 2 out of 9 staff interviewed stated that employees were using the Hoyer lift by themselves and not requesting a second person to assist.

Based on a record review and an interview with the Business Office Manager, the licensee did not comply with the section cited above when 4 employees transfered to this facility but requests for them to be associated were not completed. This posed / poses an immediate health, safety or personal rights risk to persons in care.

Based on record review and interview with the Designated Facility Administrator, the licensee did not comply with the section cited above when a minor hired to work as a server turned 18 last summer and the licensee did not obtain a background check clearance for them. This posed / poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above when the LPA observed a sharp 6 inch serrated knife in a memory care kitchenette cabinet and when she observed scissors in kitchenette drawer. These items posed/poses an immediate health, safety or personal rights risk to persons in care.

Based on a records review and interview with the Designated Facility Administrator, the licensee did not comply with the section cited above when 2 out of 3 staff files reviewed staff did not have a current first aid/CPR certification. This poses/posed a potential health, safety or personal rights risk to persons in care.

Based on a records a review and an interview with the Designated Facility Administrator, the licensee did not comply with the section cited above when 2 out of 3 staff files were missing required annual training components. This poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review and an interview with the Facility Administrator, the licensee did not comply with the section cited above as observed by they LPA during a review of staff files. In 2 of the 3 staff files, there was no proof of initial training documented. This posed a potential threat to the health, safety or personal rights risk to persons in care.

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.

Basic Services: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by resident (R1) was witnessed on video leaving the facility at 7:30pm, the facility doors were locked while the resident was still outside walking their dog. As a result, the resident was not noticed as missing and was not discovered by staff until the following morning. The coroner’s determination of death for the resident is hypothermia. Per the facility plan of operation, supervision would include health checks for all residents at a minimum of every two hours. R1 and the facility had a no check agreement from 10pm until 6am. Per the facility’s plan of operation, R1 should have been checked on between the time they exited the facility until R1’s agreed upon no check time that exceed two hours and was not consistent with the facility’s own plan of operation which poses an immediate health safety and personal rights risk to residents in care.

Basic Services: A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-Admission Appraisal and providing the other basic services specified below, either directly or through outside resources. This requirement was not met as evidenced by a care meeting taking place with resident, their authorized representatives and facility staff where resident’s increased medical needs and physical decline was discussed. Despite the admission of a change of condition and increased medical needs, no changes to the resident’s care plan or increased supervision were established which poses an immediate health, safety, or personal rights risk to residents in care.

Observation of 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 met as evidenced by statements by facility and outside care providers and documentation of concerns of Resident cognitive decline prior to the last resident care meeting with authorized provider and the resident’s death which poses a potential health, safety, and personal rights risk for residents in care.

Personnel Requirements – General: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. 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 was not met as evidenced by staff actions when encountering a known resident’s dog unattended, no staff member checked on resident for over 20 minutes prior to being discovered in the front of the building and did not display competency in their job performance by not checking on resident who was in a stated of distress which poses an immediate health, safety and personal rights risk to residents in care.

Reporting Requirements: Any suspected physical abuse that results in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within two (2) hours as required by Welfare and Institutions Code Section 15630(b)(1) Which poses a potential Health, safety and personal rights risk to residents in care.

Incidental Medical and Dental Care: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by LPA's interviews with staff and self reported incident report that details how resident was given and incorrect dose of acetaminophen on 6/25/23 when the medication was provided two hours before the next scheduled dose, which poses an immediate health, safety and personal rights risk to residents in care.

Incidental Medical and Dental Care: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by LPA's interviews with staff and self reported incident report that details how resident was given and incorrect dose of insulin on 6/9/23 when no insulin should have been provided to the resident which poses an immediate health, safety and personal rights risk to residents in care.

Incidental Medical and Dental Care: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by LPA's interviews with staff and self reported incident report that details how resident was given and incorrect doses of insulin on 4/16 and 4/26 which poses an immediate health, safety and personal rights risk to residents in care.

Based on the review of 11 resident files, the licensee did not comply with the section cited above in 1 out of 11 resident files reviewed where the LIC 602 physician's report was not updated annualy per regualtions which poses/posed a potential health, safety or personal rights risk to persons in care.

Incidental Medical and Dental Care: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by LPA's interviews with staff and self reported incident report that details how resident was given and additional dose of weekly medication which poses an immeated health, safety and personal rights risk to residents in care.

Reappraisals: The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: A mental/social trauma such as the loss of a loved one. This requirement was not met as evidenced by facility staff did not arrange for R1 to be reappraised after being informed of R1’s statements of suicidal ideation on 5/14/22 which poses an immediate health, safety and personal rights risk to residents in care.

Incidental Medical and Dental Care: The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement was not met as evidenced by when staff discovered R1 the staff did not immediately contact 911 for emergency services and instead sought additional support from additional facility staff which may have delayed first responders from initiating timely aid to the resident which poses an immediate health, safety and personal right risk to residents in care.

Additional Personal Rights of Residents in Privately Operated Facilities: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by facility did not provide enhanced safety checks for resident who expressed suicidal ideation on 5/14/22 resulting in resident committing suicide on 5/30/22 which poses an immediate health, safety and personal rights risk to residents in care.

Personnel Requirements: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. 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 was not met as evidenced by LPAs observation of camera recordings of the incident between R1 and R2 in a common area of the memory care unit where no staff were present to intervene and meet the needs of the resident which poses an immediate health and safety risk to residents in care.

Personal Rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by multiple acts of aggression by R2 against R1 documented by the facility which poses a potential health and safety risk to residents in care.