Las Villas Del Norte

(5) Facility staff shall ensure the continued safety of residents if they wander away from the facility without violating Sections 87468.1, Personal Rights of Residents in All Facilities and Section 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities. This requirement was not met as evidenced by: Based on interviews conducted and records reviewed, the fire alarm was pulled which disarmed all exit doors resulting in R1 eloping from the facility with no staff supervision. R1 was located by law enforcement a mile away from the facility. This poses a potential health and safety risk to residents in care.

(5) Facility staff shall ensure the continued safety of residents if they wander away from the facility without violating Sections 87468.1, Personal Rights of Residents in All Facilities and Section 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities. This requirement was not met as evidenced by: Based on interviews conducted and records reviewed, facility staff failed to ensure the courtyard gate was secured after knowing all doors had been disarmed. Furthermore, R1 eloped from the facility with no staff supervision and was returned by law enforcement. This poses a potential health and safety risk to residents in care.

Safe, healthful, comfortable accommodations

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This requirement is met as in evidence in: Based on records and interviews the licensee did not provide healfull and comfortable accomodations in 1 of 51 persons in the memory care unit which posed a potential Personal Rights risk to persons in care

(a) (2) (A) Surfaces such as floors, chairs, toilets, sinks, counters and tabletops shall be cleaned and disinfected on a regular basis to ensure they are safe and sanitary... This requirement was not met as evidenced by: LPA observed 6 of 9 resident bedrooms/bathrooms toured appeared to have feces stuck inside the toilet bowls, on the toilet seats, on the bathroom floor, and/or on the outside bedroom door handles. This poses a potential health/safety/personal rights risk to residents in care.

Training requirements for direct care staff:(1) 12hrs of dementia care training, 6 shall be completed before a staff member begins working independently with residents, & the 6 hrs shall be completed within the first 4 weeks of employment. All 12 hrs shall be to the care of persons with dementia. This requirement is not met as evidenced by: Based on record review the Licensee did not comply with section cited above S1, S2 and S3 work at the facility without the required initial training posing an immediate health, safety, and personal rights risk to resident in care.

Comply with all admission agreement terms

(f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not complye with the requirement noted above by overcharging Resident 1 for care. This poses a potential health and safety risk to persons in care.

Safe, healthful, comfortable accommodations

Personal Rights of Residents in All Facilities-(a) Residents...shall have all of the following personal rights:(2)To be accorded safe, healthful and comfortable accommodations, ...and equipment. This requirement was not met as evidenced by: The licensee did not ensure personal rights were maintained for residents. Based on observations, interviews, and records reviewed, R1 was found injured sitting on top of a mattress stored in their bathroom. This poses an immediate health, safety, and personal rights risk to residents in care.

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:(15) To send and receive unopened correspondence in a prompt manner.This requirement was not met as evidenced by: The licensee did not maintain the personal rights of R1 and R2. Based on interview, R1 and R2 were not provided their mail nor was it provided to their responsible party for at least 4 months. This poses in immediate threat the personal rights to residents in care.

Regular observation and documentation of resident changes

Observation of the Resident- The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. This requirement was not met as evidenced by: The licensee did not ensure R1 was provided assistance following a change in condition. Based on record review, beginning 5/24/22, R1 experienced 6 falls in less than 48 hours and was not reassessed or placed on fall precautions. This poses a potential threat to the health, safety, and personal rights risk to residents in care.

Personal Rights- (a) Residents in residential care facilities for the elderly shall have personal rights...those listed in Sections 87468.1, Personal Rights... and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility. This requirement was not met as evidenced by: The Licensee did not ensure resident's call button was answered in a timely manner. Based on records reviewed, 2 of R1's 6 call buttons on 5/14/22 took staff more than 30 minutes to respond. This poses a potential health, safety and personal rights risk to residents in care.

Personal Rights- (a) Residents in residential care facilities for the elderly shall have personal rights...those listed in Sections 87468.1, Personal Rights... and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility. This requirement was not met as evidenced by: The Licensee did not ensure resident's call light alarms were answered in a timely manner. Based on records reviewed, R1'sl light alarms were not answered in a timely manner. This poses a potential health, safety and personal rights risk to residents in care.

Protection from punishment and intimidation

Personal Rights of Residents in all Facilities-(a) Residents in all...care facilities for the elderly shall have... the following personal rights:(3) To be free from punishment, humiliation, intimidation, abuse, or other actions... such as...interfering with daily living functions such as eating, sleeping, orelimination. This requirement was not met as evidenced by: Based on observation and interviews conducted with staff and residents, the Licensee did not ensure R1 was free from physical abuse while in care which poses an immediate health, safety, and personal rights risk to residents in care.

Keep bath, laundry and kitchen floors clean

87303 Maintenance and Operations (a)(1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. this requirement was not me as evidenced by: Based on interviews, the licensee did not ensure florr surfaces were clean and sanitary, which posed a pontential health, safety and personal rights risk to 1 of 171 residents in care.

Right to freedom from abuse and neglect

87468.2 Additional Personal Rights ofResidents 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: (8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement is not met as evidenced by: Based on observation, interviews, recordreview, the licensee did not ensure residentswere free from sexual abuse in 3 of 166 persons in care [R1, R2, and R3] which posed an immediate Health, Safety, or Personal Rights risk to persons in care.

Right to sufficient care and qualified staff

Additional Personal Rights of Residents in ...Facilities: (a) In addition to the rights listed ...residents...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...to meet their needs. This requirement was not met by: Based on record review and interviews, the Licensee did not comply with the above allegation with one resident. On 4/24/22, R1 pressed their call button for help at 5:41pm, but was not provided assistance by staff. 911 respond at 6:35pm. This was an immediate safety risk to R1.

Call 9-1-1 for imminent health threats

Incidental Medical and 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 including, but not limited to, an apparent life-threatening medical crisis. This requirement is not met as evidenced by: Based on interviews, the licensee did not contact 911 or obtain emergency medical services for 1 out of 160 residents. This posed an immediate health and safety risk to residents in care.