Silvergate San Marcos Retirement Residence

INCIDENTAL MEDICAL & 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…” This requirement is not met as evidenced by: Based on outside source records and interviews, on 04/20/20, the licensee, did not call 911 for 1:79 residents in care until two (2) hours after R1 sustained an unwitnessed fall. R1, who has a history of traumatic injury to the head, sustained an acute subdural hematoma caused by blunt head trauma from a fall which later resulted in death. This poses an immediate health and safety risk to persons 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…”. This requirement is not met as evidenced by: Based on facility records and interviews, the licensee did not reappraise 1:79 residents in care when a change in condition occurred. This poses a possible health and safety risk to persons in care.

INCIDENTAL MEDICAL & 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…” This requirement is not met as evidenced by: Based on outside source records and interviews, on 04/20/20, the licensee, did not call 911 for 1:79 residents in care until two (2) hours after R1 sustained an unwitnessed fall. R1, who has a history of traumatic injury to the head, sustained an acute subdural hematoma caused by blunt head trauma from a fall which later resulted in death. This poses an immediate health and safety risk to persons in care.

PERSONAL RIGHTS – “…to not be locked into any room, building or on facility premises day or night…” This requirement is not met as evidenced by: Based on interviews, facility records and outside source records, 1:79 (R1) residents were placed into the locked dementia unit with out a physician’s diagnosis of dementia or cognitive impairment. This poses a possible health & safety risk to persons in care.