Atria Collwood

Dignity in personal relationships

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…” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not treat 1 of 83 residents (R1) with dignity. This posed a potential personal rights risk to persons in care.

Right to protection from involuntary transfer or discharge

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: “(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (20) To be protected from involuntary transfers, discharges, and evictions.” Based on records and interviews, Licensee did ensure that 1 of 83 residents (R1) was protected from involuntary discharge and/or eviction. This posed a potential personal rights risk to persons in care.

Health and Safety Code 1569.657: “(a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative, if any, written notice of the rate increase within two business days after initially providing services at the new level of care. The notice shall include a detailed explanation of the additional services to be provided at the new level of care and an accompanying itemization of the charges.” This requirement was not met, as evidenced by: Based on records review and interviews: For 1 of 83 residents (R1) who had a rate increase due to change in level of care, Licensee did not provide the resident and the resident’s representative written notice of the rate increase, to include a detailed explanation of the additional services to be provided at the new level of care and an accompanying itemization of the charges, within two business days after initially providing services at the new level of care. This posted a potential personal rights risk to persons in care.

Dignity in personal relationships

Right to protection from involuntary transfer or discharge

87224 Eviction Procedures: “(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required…(1) Nonpayment of the rate for basic services within ten days of the due date.” This requirement was not met, as evidenced by: Based on records and interviews, Licensee issued a thirty (30) days written notice to 1 of 85 residents (R1) for nonpayment of basic services, but Licensee claimed a figure which was beyond the amount that was more than ten days past due. This posed a potential personal rights risk to persons in care.

87224 Eviction Procedures: “(f) A written report of any eviction shall be sent to the licensing agency within five (5) days.” This requirement was not met, as evidenced by: Based on records review, Licensee did not send a written report of eviction regarding 1 of 85 residents (R1) to the licensing agency within five (5) days. This posed a potential personal rights risk to persons in care.

Facility maintenance and healthful environment

87307 Personal Accommodations and Services: “(d) The following space and safety provisions shall apply to all facilities: (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.” This requirement was not met, as evidenced by: Based on LPA observation and interviews, Licensee did not provide a safe and healthful environment to 1 of 88 residents (R1), which posed a potential health, safety, and personal rights risk to persons in care.

Personal assistance and care for required daily activities

87464 Basic Services: “(f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident…with those activities of daily living such as dressing, eating, bathing…” This requirement was not met, as evidenced by: Based on LPA observation, records, and interviews: Licensee did not provide all personal assistance and care that was needed by 1 of 88 residents (R1), which posed a potential health and personal rights risk to persons in care.

Based on records review and manager interview, for five (5) of five (5) sampled residents [R1 through R5], Licensee did not have in their record of care the name, address, and telephone number of the residents’ dentist to be called in an emergency, as required. This posed a potential health risk to persons in care.

Based on LPA observation and records review, Licensee used delayed egress devices on two (2) exterior doors, but did not ensure that the facility’s fire clearance included approval of delayed egress devices. This poses an immediate safety risk to 94 of 94 residents (R1 through Resident #94) in care.

Record annual routine visit documentation

Based on record review and manager interview, Licensee did not ensure that 1 of 5 sampled residents (R1) had documentation of an annual routine visit with a licensed medical professional. This posed a potential health risk to persons in care.

Include required health screening documents

Based on record review and manager interviews, Licensee did not ensure that 2 of 5 sampled staff (S2 and S3) records contained a health screening, as specified in Section 87411, Personnel Requirements – General. This posed a potential health risk to 95 of 95 residents [Resident #1 (R1) through Resident #95 (R95)] in care.

Based on record review and manager interviews, Licensee did not ensure that 1 of 46 staff (S1) obtained a California clearance or a criminal record exemption as required by the Department, prior to working in the licensed facility. This posed an immediate safety risk to 95 of 95 residents [Resident #1 (R1) through Resident #95 (R95)] in care.

First aid training requirements

Based on record review and manager interviews, Licensee did not ensure that 1 of 5 sampled staff (S3) records contained proof of current First Aid Training from persons qualified by such agencies as the American Red Cross. This posed a potential health risk to 95 of 95 residents [Resident #1 (R1) through Resident #95 (R95)] in care.

Right to sufficient care and qualified staff

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: “(a) …residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in…competency to meet their needs.” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not ensure that 1 of 98 residents (R1) had the care and supervision needed to meet their individual needs. This posed a potential safety risk to persons in care.

Heat occupied rooms to minimum temperature

Maintenance and Operation (b) A comfortable temperature for residents shall be maintained at all times.(1) The facility shall heat rooms that residents occupy to a minimum of 68 degree F, (20 degrees C).This requirement was not met as evidenced by: Based on a resident and staff interviews the facility did not provide alternative forms of heat during a power outage to R1's room.This posed a potential Personal Rights risk to [R1], 1:91 residents in care.

Reporting Requirements (d) The Licensee shall notify… all residents… in writing within two business days of…the following… (5) A utility company has sent a notice of intent to terminate electricity… within…15 days….This requirement was not met as evidenced by: Based on a resident and staff interviews the facility did not provide advanced written notice of a planned power outage in December to R1.This posed a potential Health and Safety, and Personal Rights risk to [R1], 1:91 residents in care.

Maintenance and Operation (h) Emergency lighting shall be maintained. ...this shall include flashlights, or other battery powered lighting, readily available in appropriate areas accessible to residents and staff.This requirement was not met as evidenced by: Based on a resident and staff interviews the facility did not provide readily available emergency lighting or heat to R1's room.This posed a potential safety risk to [R1], 1:91 care.

Protection from punishment and intimidation

(a) Residents shall have all of the following personal rights:...(3)To be free from intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.This requirement was not met: Based on records reviewed the licensee intimidated 1 of 88 persons in care (R1]) into signing documents which posed a potential Personal Rights risk to persons in care.

Maintain facilities for fire and panic safety

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life... against fire and panic. (1) Nonambulatory persons.(2) Bedridden personsThis requirement was not met as evidenced by: Based on interviews and record reviews the Licensee did not address 4 facility doors that did not pass a fire system inspection (conducted on April 9,2024) due to the doors not latching or dragging.This posed an immediate threat tol 92 residents in care.This is an amended version of the original report dated 5/29/24.

Personal assistance and care for required daily activities

(f)…shall at a minimum include…(4) Personal assistance and care…with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications. This requirement was not met as evidenced by: Based on interviews, the Licensee did not ensure R1 was provided personal assistance, which posed a potential health, safety, and personal rights risk to 1 of 185 residents in care.

87218 Theft and Loss: “(a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153. (1) The initial personal property inventory shall be completed by the licensee, and the resident, or the resident’s representative.” This requirement was not met, as evidenced by: Based on records review and interview, for 1 of 87 residents (R1), Licensee did not maintain a personal property inventory, completed by the licensee and the resident and/or their representative, which posed a potential personal rights risk to persons in care.

1569.153 Theft and Loss Program, ect.: "A theft and loss program shall be implemented by the residential care facilities for the elderly…The program shall include all of the following: (c) Documentation of lost and stolen resident property with a value of twenty-five dollars ($25) or more within 72 hours of the discovery…for the past 12 months…” This requirement was not met, as evidenced by: Based on records review and interview, Licensee did not maintain documentation of lost and stolen resident property with a value of twenty-five dollars ($25) or more within the past 12 months. This posed a potential personal rights risk to 87 of 87 residents (R1 through Resident #87).

Reporting Requirements (1) A written report shall be submitted to the licensing agency…within seven days of the occurrence of… (D) Any incident which threatens the welfare, safety or health of any resident…This requirement was not met as evidenced by: Based on records review and interviews, licensee did not submit written reports to licensing to 1 of 80 residents. This posed a potential health and safety risk to residents in care.

Staff training in personal care activities

Personnel Requirements – General(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual trainingThis requirement was not met as evidence by:.This requirement was not met as evidenced by: Based on record reviews and interviews, staff did not receive initial training.This posed a potential health risk to residents in care.

Facility personnel sufficiency and competence

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 was not met as evidenced by: Based on records review and interviews, facility personnel were not sufficient to meet the needs of (R1) 1 out of 80 residents.This posed a potential health risk to residents in care.

Protection from punishment and intimidation

Personal Rights of Residents in All Facilities (a)Residents …shall have all the following personal rights: (3) To be free from… intimidation, abuse, or other actions of a punitive nature…This requirement was not met as evidenced by: Based on interviews, staff spoke in an intimidating manner to (add #) of 80 residents. This posed a potential personal rights risk to residents in care.

Residents in all facilities must have rights

Personal Rights of Residents in All FacilitiesResidents…shall have all the following personal rights: To be accorded safe, healthful and comfortable accommodations…This requirement was not met as evidenced by: Based on records review and interviews, the facility did not accord healthful accommodations to (R1) one of 80 residents in care.This posed a potential personal rights risk to residents in care.

Store centrally held medications in locked secure place

Incidental Medical and Dental Care(h)(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible…This requirement was not met as evidenced by: Based on interviews and observations, facility did not keep medications in safe and locked place. This posed a potential safety risk to 4 of 80 residents in care.

Incidental Medical and Dental Care. If the resident is unable to determine...own need for a prescription or nonprescription PRN medication, ...facility staff ...assist ... provided all of the...requirements... (2) 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 records review and interviews, facility personnel did not give medication as prescribed to (R1) one out of 80residents.This posed an immediate health risk to a resident in care.

Care and supervision as defined by statute and rules

Basic Services (f)(1) (f) Basic services shall at a minimum include:(1) Care and supervision.This requirement was not met as evidenced by: Based on records review and interviews, facility personnel did not provide basic care services to (R1) one out of 80 residents.This posed an immediate health risk to a resident in care.

Licensee responsibility for records confidentiality

(c) All information and records obtained ... regarding residents shall be confidential.(1) The licensee shall be responsible for....safeguarding the confidentiality of their contents....all employees shall reveal...confidential information only upon the resident's written consent or... designated representative.This requirement was not met as evidenced by: Based in LPA's interview, observation, and records reviews staff did not safegaurd confidential records for 1 out of 85 residents in care.This posed a potential personal rights violation for residents in care.

Use slip-resistant surfaces in bathing areas

87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows:(5) Non-skid mats or strips shall be used in all bathtubs and showers.This requirement was not met as evidence by: Based on observations and interviews the licensee did not provide non-skid mats or strips in bathtubs or showers in 2 of 81 persons in care [R1 and R2] which posed a safety risk to persons in care.”

Maintain facility in clean, safe, sanitary condition

Maintenance and Operation (a) The facility shall be...safe...and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. Based on an interview with the Executive Director (ED) the facility did not maintain good repair to 1 out of 82 resident rooms. This posed a potential safety risk to residents in care.

Right to freedom from abuse and neglect

Additional Personal Rights of Residents in Privately Operated Facilities: “…residents in privately operated residential care facilities shall have all of the following personal rights:…to be free from mental, physical, or sexual abuse.” This requirement is not met, as evidenced by: Based on records and interviews, Licensee’s staff caused sexual abuse on 2 residents [R1 and R2] of 93 in care, which posed an immediate personal rights risk to persons in care.

Right to personal privacy in daily care

Personal Rights of Residents in All Facilities: “Residents in all residential care facilities shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.” Based on records and interviews, Licensee’s staff, through sexual harassment, violated the dignity of 1 resident [R1] of 96 in care, which posed an immediate personal rights risk to persons in care.