Belmont Village Cardiff

87507 Admission Agreement – “All basic and optional services, rates, and charges shall be specified in the admission agreement. The licensee shall not charge for services that are not provided.”The following requirement has not been met as evidenced by: Based on documentation, residents were charged for memory care services and the “Circle of Friends” program despite not receiving or attending such services. This violates the admission agreement and created a financial burden on residents, which poses a potential, health, safety, or personal rights risk to residents in care.

87211 — Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: The following requirement has not been met as evidenced by: The facility did not timely report R1’s fall, overnight time on the floor, or subsequent hospitalization to the licensing agency. Supervisory staff were also not promptly notified of the outage and incident until contact by the responsible party the following day, which poses a potential, health, safety, or personal rights risk to residents in care.

87212 Emergency Disaster Plan(a) Each facility shall have a disaster and mass casualty plan of action. The plan shall be in writing and shall be readily available.The following requirement has not been met as evidenced by: The facility did not have emergency adequate lighting in resident 1's room possibly contributing to a fall sustaining injuries, which poses an immediate health, safety, or personal rights risk to residents in care.

87411 — Personnel Requirements (sufficient, competent staff to meet resident needs at all times) The following requirement has not been met as evidenced by: On 06/18/2021 during a facility-wide power outage, R1 fell in their apartment and remained on the floor overnight without staff assistance until ~0715 on 06/19/2021. Required welfare checks and timely assistance were not provided, resulting in unmet care needs and contributing to a serious injury later diagnosed at the hospital. which poses an immediate, health, safety, or personal rights risk to residents in care.

87465(a)(1) — Incidental Medical and Dental Care (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(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.The following requirement has not been met as evidenced by: Following the known fall on the morning of 06/19/2021, facility staff did not arrange timely medical evaluation for R1. The responsible party transported R1 to the hospital several hours later, where a spinal cord injury was diagnosed. Facility did not ensure prompt medical care was obtained. which poses an immediate, health, safety, or personal rights risk to residents in care.

87211(a)(1)(D) Reporting Requirements – “The licensee shall report by telephone to the licensing agency, local law enforcement, and the responsible person any suspected physical abuse … immediately, or within 24 hours.”The following requirement has not been met as evidenced by: Based on record review, the facility failed to immediately notify law enforcement when Resident #1 disclosed possible sexual abuse on 03/09/22. Law enforcement was not contacted until 03/10/22. This posed an immediate health and safety risk to all residents in care.

87463 Reappraisals – “The licensee shall arrange a meeting with the resident and/or representative when a significant change occurs in the resident’s condition to determine if the facility can continue to meet the resident’s needs.”The following requirement has not been met as evidenced by: Based on file review, residents with dementia and wandering behavior were moved from memory care into assisted living without evidence of reappraisal, while continuing to require memory care services. This resulted in residents not being placed at the appropriate level of care, which poses a potential, health, safety, or personal rights risk to residents in care.

87464(a)(2) Basic Services – Personal Care and Supervision – “Basic services shall at a minimum include: (2) Personal assistance and care as needed by the resident … including assistance with bathing, grooming, dressing, mobility, and other personal needs.”The following requirement has not been met as evidenced by: Based on record review, residents reported not being assisted with showers. This poses a potential, health and safety risk to residents in care.

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:(4) 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. The following requirement has not been met as evidenced by: Based on record review, residents reported being left in wheelchairs all day. This poses a potential, health and safety risk to residents in care.

87465 Incidental Medical and Dental Care: “(a)(4) The licensee shall assist residents with self-administered medications as needed.” This requirement was not met, as evidenced by: Based on records and interviews, the licensee did not assist 2 of 140 residents (R1 & R2) with self-administered medications as needed/prescribed, which posed a potential health risk to persons in care.

Personal Rights of Residents in All Facilities.Residents in all residential care facilities for the elderly shall have all of the following personal rights:To wear their own clothes; to keep and use their own personal possessions, including their toilet articles; and to keep and be allowed to spend their own money.This requirement is not met as evidenced by: Based on interviews conducted, 1 out of 139 residents’ furniture was discarded without permission from the resident or RP in April 2020. Therefore, posing a potential personal rights risk to residents in care.

87465 Incidental Medical and Dental Care (d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration… this requirement was not met as evidenced by: Based on interviews and records review, the Licensee did not assist R1 with self-administration of a PRN medication as prescribed. This posed a potential health risk to one of 139 of residents in care.

Care of Persons with Dementia - The following shall be stored inaccessible to residents with dementia: other items that could constitute a danger to the resident(s). This requirement was not met as evidenced by observation of unsecured cleaning supplies in Memory Care area, inside an unlocked cabinet. This posed an immediate safety risk to 23 residents in care.