Follow-up on corrections·October 11, 2024

Citations

15 citations recorded^*CCLD

• 87468.1(a)(12)Type B

  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: (12)…to keep and use their own personal possessions, including their toilet articles…” This requirement was not met, as evidenced by: Based on interviews, Licensee did not uphold the right of 2 of 6 residents (R2 and R5) to keep and use their own personal possessions, including their toilet articles. This posed a potential personal rights risk to persons in care.

• 87101(c)(3)Type B

  87101 Definitions: “(c)(3) ‘Care and Supervision’ shall include, but not be limited to, any one or more of the following activities provided by a person or facility to meet the needs of the residents: (A) Assistance in dressing, grooming, bathing and other personal hygiene…” This requirement was not met, as evidenced by: Based on interviews, Licensee did not meet the grooming/hygiene needs of 1 of 6 residents (R1). This posed a potential health and personal rights risk to persons in care.

• 87307(a)(3)Type B

  87307 Personal Accommodations and Services: “(a) The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident.” This requirement was not met, as evidenced by: Based on interviews, Licensee did not ensure that 1 of 6 residents (R1) had supplies necessary for personal care and maintenance of adequate hygiene practice readily available to them. This posed a potential health and personal rights risks to persons in care.

• 87412(f)Type B

  87412 Personnel Records: “(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours.” This requirement was not met, as evidenced by: Based on LPA observation and staff interviews, for 9 of 9 staff (S1 through S9), Licensee did not ensure that their personnel records were available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. This posed a potential safety risk to persons in care.

• 87456(a)(2)Type B

  87456 Evaluation of Suitability for Admission: “(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall…: (2) Perform a pre-admission appraisal.” This requirement was not met, as evidenced by: Based on records review and manager interview, for 1 of 5 residents (R4), Licensee did not have on file a completed LIC603 Pre-Placement Appraisal (or equivalent pre-admission appraisal document) to evidence that they performed a pre-admission appraisal to evaluate his/her suitability, prior to accepting the resident for care. This posed a potential health, safety, and personal rights risk to persons in care.

• 87458(a)Type B

  87458 Medical Assessment: “(a) Prior to a person’s acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use form LIC602…to obtain the medical assessment.” This requirement was not met, as evidenced by: Based on records review and manager interview, for 1 of 5 residents (R4), prior to the person’s acceptance as a resident, Licensee did not obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. This posed a potential health, safety, and personal rights risk to persons in care.

• 87458(b)Type B

  87458 Medical Assessment: “(b) The medical assessment shall include, but not be limited to: …results of an examination for communicable tuberculosis…” This requirement was not met, as evidenced by: Based on records review and manager interview, for 3 of 5 residents (R2, R3, and R4), Licensee did not ensure that the resident had a medical assessment that also included the results of a complete examination for communicable tuberculosis. This posed a potential health risk to persons in care.

• 87467(a)Type B

  87467 Resident Participation in Decisionmaking: “(a) Prior to, or within two weeks of the resident’s admission, the licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, and any other appropriate parties, to prepare a written record of care the resident will receive in the facility, and the resident’s preferences regarding the services provided at the facility.” This requirement was not met, as evidenced by: Based on records reviewed and interviews, for 4 of 5 residents (R1, R2, R4, and R5), Licensee did not have on file a completed LIC625 Appraisal/Needs and Services Plan (or equivalent “written record of care the resident will receive”), to include the resident’s preferences regarding the services provided at the facility. This posed a potential health and personal rights risks to persons in care.

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• 87705(c)(5)Type B

  87705 Care of Persons with Dementia: “(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: “(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually…” This requirement was not met, as evidenced by: Based on records and manager interview, for 1 of 5 residents (R5), who was diagnosed with dementia, Licensee did not ensure that they had a medical assessment and care reappraisal done at least annually. This posed a potential health risk to persons in care.

• 87705(j)Type B

  87705 Care of Persons with Dementia: “(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.” This requirement was not met, as evidenced by: Based on LPA observation and staff interviews, Licensee did not continuously maintain an auditory device or other staff alert feature to monitor exits. This posed a potential safety risk to 6 of 6 residents (R1 through R6) in care.

• 87211(a)(1)(D)Type B

  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: (1) 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...(D) Any incident which threatens the welfare, safety or health of any resident." This requirement was not met, as evidenced by: Based on records and interviews, 1 of 5 residents (R1) had incidents which threatened their welfare/health, and Licensee did not submit a written report of the incidents to the licensing agency and the person responsible for the resident within seven days of incident occurrence. This posed a potential health risk to persons in care.

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• 87466Type B

  87466 Observation of the Resident: “The licensee shall ensure that residents are regularly observed for changes in physical…functioning... When changes such as…deterioration of…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 records and interviews, 1 of 5 residents (R1) had a deterioration of a physical health condition which staff observed, but Licensee did not ensure that this change was documented and brought to the attention of the resident’s physician (or their staff) and responsible person. This posed a potential health risk to persons in care.

• 87468.2(a)(16)Type B

  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: (16) To written notice of any room changes at least 30 days in advance unless a room change is agreed to by the resident, required to fill a vacant bed, or necessary due to an emergency.” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not ensure that 1 of 5 residents (R1) received written notice of room change at least 30 days in advance. The room change was not done with resident consent, or to fill a vacant bed, or due to an emergency. This posed a potential personal rights risk to persons in care.

• 87652(b)(3)Type A

  87625 Managed Incontinence: “(b)…the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.” This requirement was not met, as evidenced by: Based on interviews and photographic evidence: For 1 of 5 residents (R1), who was incontinent, Licensee did not ensure that they were kept clean and dry. This posed an immediate health and personal rights risk to persons in care.

• 87303(b)(2)Type B

  87303 Maintenance and Operation: “(b) A comfortable temperature for residents shall be maintained at all times. (2) The facility shall cool rooms to a comfortable range, between 78 degrees F…and 85 degrees F…” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not at all times maintain a comfortable temperature for residents, by cooling rooms to a comfortable range between 78 degrees F and 85 degrees F. This posed a potential health and personal rights risk to 5 of 5 residents (R1 through R5) in care.

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