Carlton Plaza of Elk Grove

"(4) The licensee shall assist residents with self-administered medications as needed." This requirement was not met as evidenced by: Based on interviews and record review, a resident (R1) did not receive their regularly prescribed medication for more than six days, which poses an immediate health, safety, and/or personal rights risk.

"A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified ... Any incident which threatens the welfare, safety or health of any resident..." This requirement was not met as evidenced by: Based on interview and record review, an incident report was not sent to CCLD regarding a medication error, which poses a potential health, safety, and/or personal rights risk.

"(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 was not met as evidenced by: Based on record review and interview, a resident's medication was mismanaged, which poses an immediate health, safety, and/or personal rights risk.

"(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:" This requirement was not met as evidenced by: Based on record review and interview, staff nurses were not trained in the use of a medication-releasing intravaginal ring which they had been inserting for a resident, which poses a potential health, safety, and/or personal rights risk.

"Every facility required to be licensed under this chapter shall provide at least the following basic services: ... Being aware of the resident's general whereabouts, although the resident may travel independently in the community." This requirement was not met as evidenced by: Based on interviews, record review, and observation, a resident's location was unknown for a period of approximately four hours while they were unsupervised in the community, which poses/posed an immediate health, safety, and/or personal rights risk.

“(a) The facility shall be clean, safe, sanitary and in good repair at all times…” This requirement was not met as evidenced by: Based on interviews and record review, a resident’s room was not safe or sanitary, which poses an immediate health and safety risk.

“Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: … A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified … Any incident which threatens the welfare, safety or health of any resident…” This requirement was not met as evidenced by: Based on record review, an incident report was not sent to LPA Moleski regarding R1’s hospitalization on 8/8/24, which poses a potential health, safety, and/or personal rights risk.

“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: Based on interviews and record review, appropriate assistance was not provided to R1 during their quarantine period, which poses an immediate health, safety, and/or personal rights risk.

Based on interview and record review, S6 needs to be re-fingerprinted, and has been working without being associated to this facility, which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review, R1 and R2 did not have annually updated LIC 602s on file, which poses/posed a potential health, safety or personal rights risk to persons in care.

"A theft and loss program shall be implemented by the residential care facilities for the elderly within 90 days after January 1, 1989. The program shall include all of the following [subsections (a) through (m)]."This requirement was not met as evidenced by: Based on observation, interviews, and record reviews, all required elements of the theft and loss program per 1569.153(a)-(m) were not implemented, which poses a potential health, safety, and personal rights risk.

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: Based on record review and interviews, there are not a sufficient number of staff at this facility to answer resident calls in a timely manner, which poses a potential health and safety risk.

Based on review of S3, S4 and S7's personnel records, the licensee did not ensure S3, S4, or S7 maintained active first aid certifications, which poses/posed a potential health, safety or personal rights risk to persons in care.

“PPE shall be removed and discarded in the nearest appropriate waste receptacle with a tight-fitting cover immediately upon completing a task.” This was not met based on LPA interviews with staff members.

87211(a)(2) Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports...(2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents...This was not met as evidenced by: Based on the incident report dated 1/19/2023 received from the licensee there was a Covid 19 outbreak that began on 1/15/2023. According to Title 22 Regulations, the outbreak was not reported within regulatory timelines. This poses an immediate health and safety risk to persons in care.

87465 Incidental Medical and Dental Care. (d) If the resident is unable to determine his/her own need for a...nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff..., shall be permitted to assist the resident with self-administration provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement is not met as evidenced by: Based on interview and record review, a Quetiapine as needed medication for R1 is missing 22 pills from original container filled on 7/17/21 with no record from staff to indicate when medication was given, dosage taken, and R1s response to medication. This poses an immediate health and safety risk to residents in care.

87628(b)(4) Diabetes. (b)In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (4) Providing modified diets as prescribed by a resident's physician as specified in Section 87555(b)(7). This requirement is not met as evidenced by: Based on interview, R1 was provided a maple syrup product by staff which was not low or sugar free and inconsistent with R1’s modified diet physician's order. This poses a potential health and safety risk to residents in care.

Reporting RequirementsEach licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: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: A review of submitted SIRs of which one was not found for the previous date R1 AWOL'd on 4/22/22.Based on interviews the Administrator did not submit a report for the AWOL incident that occurred on 4/22/22. This possess an immediate health and safety risk to residents in care.

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Incidental Medical and Dental CareIn all facilities licensed for sixteen (16) persons or more...designated as having primary responsibility for assuring that each resident receives needed first aid... This requirement is not met as evidenced by:R1 did not receive first aid due to eatingBased on interviews the Administrator confirmed that R1 did not receive first aid because after eating the family took R1 on an outting. This possess an immediate health and safety risk to residents in care.

Care of Persons with DementiaThe licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by: the resident awol'd twice from the facility and the front door alarm did not soundBased on interviews the resident eloped out the front door. This possess an immediate health and safety risk to residents in care.

Care of Persons with DementiaIn addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including:Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. This requirement is not met as evidenced by: the resident awol'd twice from the facilityBased on the facility did not implement any new measures to prevent future awols from re-occurring. This possess an immediate health and safety risk to residents in care.

Care of Persons with DementiaThe following initial and continuing requirements must be met…without violating Section 87468, Personal Rights, facility staff shall ensure the continued safety of residents if they wander away from the facility. This requirement is not met as evidenced by: R1 wandered from the facility at least twice.Based on interviews and documentation, the Licensee did not ensure supervision resulting in R1 wandering away from the facility twice with the most recent being approximately 8 hours. This possess an immediate health and safety risk to residents in care.

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. The licensee shall assist residents with self administered medications as needed. This regulation was not met as evidenced by based on LPA’s interviews and a review of the facility records, this facility did not ensure that the correct medication was administered to R1 on 5-27-21 and 9-26-21. R1 received the wrong medication and dosage on each date.