Victorian Manor

Limit postural support devices to mobility needs

Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 1 client, for not able provide documentation for medical order for half bed rail, which poses an immediate health, safety or personal rights risk to persons in care.

Review and revise record after changes

RESIDENT PARTICIPATION IN DECISIONMAKING...the licensee shall arrange ... to prepare a written record of the care the resident will receive in the facility....review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. This requirement was not met, based on review of Needs and Services Plan for client #1. Licensee failed to ensure that the written record was acknowledged and signed by resident or his representative, which posed a potential health, safety or personal rights risk to residents in care.

CARE OF PERSONS WITH DEMENTIALicensees who accept and retain residents with dementia shall be responsible for ensuring there is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal.This requirement was not met, as staff did not adequately supervise client on 8/3/23 when he eloped from facility. Licensee failed to ensure client's safety, which posed a potential health, safety or personla rights risk to clients in care.

CARE OF PERSONS WITH DEMENTIAEach resident with dementia shall have an annual medical assessment... and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. When any medical assessment, appraisal, or observation indicates that the resident’s dementia care needs have changed, corresponding changes shall be made in the care and supervision...This requirement was not met, as MD report is over 2 years old & appraisal does not adequately address wandering behavior.

Grounds for eviction listed for residents

87224(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 except as otherwise specified in paragraph (5). This requirement was not met as evidenced by : Based on interviews and record reviews the facility gave an immediate eviction notice, per Title 22, a 30-day notice to R1 is required which poses an immediate health, safety, or personal rights risk to persons in care.

Report specified resident events within seven days

87211 Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports as the Department...(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.. The requirement is not met as evidenced by resident #1 was transferred to the hospital on 6/5/2023 and it was not reported to CCLD.

Update reappraisal at required intervals

87463 Reappraisals..(a) The pre-admission appraisal shall be updated,.. The reappraisals shall document changes in the resident's physical,.... This requirement is not met as evidenced by R1 had a change in health condition and needs and services plan was not updated in a timely fashion which posed a potential health risks to resident in care.

87468.2Additional Personal Rights of Residents in Privately Operated Facilities..(a)In addition to the rights listed in Section 87468.1,..(7) To fully participate in planning their care, including the right to attend and participate in meetings or communications regarding care and services to be provided,..This requirement is not met as evidenced by R1's needs and services plan was updated on 6/21/2023, however, the signature page indicating it was reviewed by R1 was blank which posed a potential health risk to resident in care.