Villa Lorena

Right to freedom from abuse and neglect

87468.2 (a)(8) Additional Personal Rights of Residents in Privately Operated Facilities (a)(8) In addition to rights listed in Section 87468.1, Residents shall have the following personal rights…to be free from physical abuse. This requirement was not met as evidenced by: Based on interviews with staff and outside sources, records review, and photographs, Facility staff handled resident roughly resulting in bruises. Licensee did not comply with regulation for 1 of 69 residents. This caused an immediate health and safety risk to residents in care.

Right to access and copy personal medical records

87468.2(a) In addition to the rights listed in Section 87468.1…personal rights:(19)To have prompt access to review all of their records…2 business days..This requirement was not met as evidenced by: Based on records review and interviews, the licensee did not provide prompt access to review records in 1 of 63 persons in care, which posed a potential Personal Rights risk to persons in care.

Resident records.(b) Each resident’s record .... information:(13)Continuing record of any illness, injury, or medical or dental care, when it impacts the resident's ability to function or needed services. Based on records review and interviews, the licensee did not update records in 1 of 63 persons in care, which posed a potential Personal Rights risk to persons in care.

Prohibit false or misleading facility statements

False Claims.No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement.....the services provided by the facility. This requirement was not met as evidenced by: Based on interviews and record reviews, The licensee staff faslified documents for COVID-19 results for R1. This posed a potential personal rights risk to all residents in in care.

Maintain facility in clean, safe, sanitary condition

87303 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not met as evidence in; Based on observations and interviews the licensee did not treat for mold in 1 of XX (GET CENSUS) persons in care which posed a potential Health and Safety risk to persons in care.

87470 Infection Control Requirements (a) A licensee shall ensure that infection control practices are maintained as follows: This requirement was not mer as evidenced by: Based on interviews, the licensee did not ensure staff followed COVID-19 guidance, which posed a potential Health, Safety, and Personal Rights risk to all persons in care.

Prompt responses to resident communications

87468.1 Personal Rights of Residents in All Facilities (a) Residents...shall have... the following personal rights:(9) To have communications to the licensee from their representatives answered promptly and appropriately. This requirement was not met as evidence in; Based on interviews and records review the licensee did not communicate with residents promptly and appropriately in 3 of of XX persons in care which posed a potential Personal Rights risk to persons in care.

Report specified resident events within seven days

Reporting Requirements.(a) Each licensee... reports as the Department may require...(1) A written report shall be submitted to the licensing agency and to the person responsible... within seven days of the occurrence..This requirement was not met as evidenced by: This requirement is not met as evidenced by: Based on record review and interviews, the licensee did not ensure an incident report was completed forX out of X residents [R1], which poses a potential health and safety risk to residents in care.

Safe, healthful, comfortable accommodations

Personal Rights of Residents in All Facilities. Residents...facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: This requirement is not met as evidenced by: Based on interviews the licensee did not ensure resident’s safety equipment was operable for 1 out of 71 residents [R1] due to the wander guard being inoperable for approximately threedays, which posed a potential safety and/or personal rights to residents in care.

Dignity in personal relationships

Personal Rights of Residents in All Facilities. Residents in...facilities...shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on interviews the licensee did not accord dignity to 1 out of 71 residents [R1] when they covered R1’s laptop camera, which posed a potential safety and/or personal rights to residents in care.

1569.625 Staff training, legislative findings, contents (b)(2) In addition to paragraph (1) training requirements shall also include an additional 20 hours annually... This requirement has not been met as evidenced by: Based on record review, the Licensee did not ensure that S1 had completed the 20 hours of annual training for 2020 and 2021. This poses a potential safety risk to 67 of 67 residents in care.

Facility personnel sufficiency and competence

Personnel Requirements – General: 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 based on evidence by: Based on interviews and records review, the facility failed to implement a plan or identify staff objectives to mitigate R1 and R2’s falls. This posed a potential health and safety risk to 1 out of 66 residents in care.