Ivy Park at Cathedral Hill

Keep prescriptions in original containers

87465(h)(5): The following requirements shall apply to medications which are centrally stored: (5)Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.This requirement is not met as evidenced by: Based on observation, Licensee had a physician's order for R1's medication but did not have the physical medication for R1, which is an immediate health, safety, or personal rights risk to persons in care.

Acceptance obligations tied to pre-admission appraisal needs

87464(d): Basic Services: A facility need not accept a particular resident..if a facility chooses to accept...the facility shall be responsible for meeting the resident's needs...This requirement is not met as evidenced by: Based on interviews, the Licensee accepted R1 who was considered a fall risk, but did not have a fall prevention plan in place to meet R1's needs, which is a potential health, safety, or personal rights risk to persons in care.

Right to sufficient care and qualified staff

87468.2(a)(4): Additional Personal Rights of Residents in Privately Operated Residential Care Facilities: Residents shall have the following personal rights: To care, supervision, and services that meet their individual needs...This requirement is not met as evidenced by: Based on interviews the Licensee did not ensure R1 was provided care, supervision, and services that met their individual needs when the Licensee did not contact R1's primary care physician upon receipt of their medications, which is a potential health, safety, or personal rights risk to persons in care.

Report specified resident events within seven days

87211(a)(1): Reporting Requirements: 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.This requirement is not met as evidenced by: Based on document review, Licensee did not submit a written report to the Department for each fall occurrence of R1, which is a potential health, safety, or personal rights risk to persons in care.

Regular observation and documentation of resident changes

87466: Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes... and that appropriate assistance is provided when such observation reveals unmet needs.This requirement was not met as evidenced by: Based on interviews, the Licensee did not ensure that R1 was provided with appropriate assistance after the Licensee observed them falling on multiple occasions which is an immediate health, safety, or personal rights risk to persons in care.

Certified administrator requirements and substitute coverage

This is an amendment to original report date of 11/7/2024 to identify corrected regulation section: 87405(a) The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. This was not met as evidence by: Based upon interviews with Health Service Director (S1) and Executive Director (S2) and review of resident (R1) documents it was found that S2 failed to ensure frequent checks on R1 was done as recommended, that R1's appraisal was updated including suicidal ideations with updated staffing plan, and that R1 is performing their duties, which is ultimately the responsibility of S2.

Right to sufficient care and qualified staff

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities - (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. This was not met as evidence by: Based upon interviews with Health Service Director and Executive Director and review of resident (R1) records it was found that the facility identified a need for R1’s change in level of care due to suicidal ideations. However, Executive Director and Health Service Director failed to provide care and services to meet R1’s needs, resulting in severe injury/death by means of suicide. This is an immediate health and safety & personal rights risk to residents in care.

Regular observation and documentation of resident changes

87466 Observation of the Resident: Licensee shall ensure that residents are...observed for changes in physical, mental, emotional & social functioning & that appropriate assistance is provided when such observation reveals unmet needs. When changes...or deterioration of mental ability or a physical health condition are observed, licensee shall ensure that such changes are documented & brought to the attention of the resident's physician & responsible person, if any.." This was not met as evidence by: Based upon interviews with Health Service Director (S1) and Executive Director (S2) and review of resident’s (R1) records, it was found that the facility observed and were aware of R1’s suicidal statements and change of condition, indicated on 3/28/2024 and on 4/18/2024, but failed to ensure appropriate changes to R1’s level of care was initiated or documented, leading to severe injury/death of R1. This is an immediate health & safety risk to residents in care.

Update reappraisal at required intervals

87463(a) Reappraisals – (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to..” This was not met as evidence by: Based upon interviews with Health Service Director (S1) and Executive Director (S2) and review of resident (R1) documents, it was found that the S1 identified a need for R1’s change in level of care due to suicidal ideations and hospital visit on 3/28/2024. However, Health Service Director (S1) failed to develop and document an updated care plan to address R1’s suicidal ideations and increased supervision, leading to the severe injury/death of R1. This is an immediate health & safety risk to residents in care.

Freedom to leave and not be locked in

Personal Rights of Residents in All Facilities - ..to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department. This was not met as evidence by: Based on a review of facility Incident Report and interviews with LPA Calandra and Executive Director, it was found that staff (S1) was found and admitted to have placed a table in front of resident (R1) bedroom door, preventing R1 from leaving. This is a potential health and safety risk to residents in care.

Facility personnel sufficiency and competence

87411(a) 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 is not met as evidenced by observation and interview of staff, which showed that multiple facility staff are not competent to provide the services necessary to meet resident needs.

Safe, healthful, comfortable accommodations

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:..(2) To be accorded safe,.. This requirement is not met as evidenced by record review and interview of Executive Director, which revealed that 16 out of 137 clients waited in some cases more than 289 minutes for care, which is an immediate health and safety risk to persons in care.

Provide assistance for residents medical needs

87465(a)(2): 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: (2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service. This requirement has not been met as evidenced by: This requirement has not been met as evidenced by facility staff did not call 911 immediately for R1 but instead waited to tell S1 when S1 started their shift. 911 was alerted approximately 2 hours after R1 was found unresponsive. Medical personnel were not contacted in a timely manner.

Assist residents with self-administered medication

87465 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 provide for assistance in obtaining such care, by compliance with the following: (4)The licensee shall assist residents with self-administered medications as needed.Violation of this regulation is not met as evidenced by: Based on interviews conducted, a staff member observed another staff member accidentally give R1 one tablet instead of two tablets, however caught the issue and provided R1 with another tablet. Based on record review, there was a discrepancy between a discrepancy between the physician's order and the MAR system being used by the facility, and the prescription bottle that was given by the pharmacy as the MAR system and the physician’s order indicated to provide R1 with one 200mg tablet of Lamotrigine daily, however the prescription bottle from the pharmacy indicated to provide R1 with two 100mg of Lamotrigine tablets daily. Nevertheless, the facility failed to provide R1 with his/her Lamotrigine prescription as prescribed by R1’s physician and follow up with R1's physician and/or the pharmacy for clarification

§1569.312 Basic services requirements..Every facility required to be licensed under this chapter shall provide at least the following basic services:..(a) Care and supervision as defined in Section 1569.2.Violation of this regulation is not met as evidenced by: Based on record reviewed, on 11/20/23, R1 pressed his/her call button and a staff member responded 67 minutes later. In addition, on 9/26/23, staff did not respond to R1’s call button in a timely manner as a staff responded to R1’s call 55 minutes after he/she pressed her button. Furthermore, additional record reviewed showed that it took staff 80 minutes on 9/7/23 and 120 minutes on 9/8/23 to respond to R2’s call button.

Document behavioral expression and related causes

Based on records review, the licensee did not comply with the section cited above in 4 out of 10 resident files, which poses a potential health, safety or personal rights risk to persons in care.

Obtain baseline medical assessment before resident admission

Based on records review, the licensee did not comply with the section cited above in 8 out of 10 resident files, which poses/posed a potential health, safety or personal rights risk to persons in care.

Maintain facilities for fire and panic safety

Based on observation of 2 elevators, the licensee did not ensure elevators were inspected annually in 2 out of 2 which poses a potential health, safety or personal rights risk to persons in care.

Safe, healthful, comfortable accommodations

87468.1Personal Rights of Residents in All Facilities..(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:..(2) To be accorded safe,.. This requirement is not met as evidenced by: it took facility staff 205 minutes and 46 seconds to reset R1's call cord which posed an immediate health risk to residents in care.

87555 General Food Service Requirements..(7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement is not met as evidenced by: R1 has a physician's order for mechanical soft diet, however, facility served R1 raw vegetables and other foods that R1 was not to chew which posed a potential health risk to resident in care.

§1569.312Basic services requirements..Every facility required to be licensed under this chapter shall provide at least the following basic services:..(a) Care and supervision as defined in Section 1569.2. This requirement is not met as evidenced by: R1's roommate R2 fell and there was no staff around to provide assistance which resulted R1 assisted R2 off of the floor and back to the bed which posed an immediate health risk for residents in care.

87411 Personnel Requirements - General..(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training..(3) The training shall include, but not be limited to, the following:..(C) Residents rights,.. This requirement is not met as evidenced by based on the training records provided by the facility for S1, it does not indicate that S1 has recevided the above training which posed a potential risk for residents in care.

Residents in all facilities must have rights

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:..(2) To be accorded safe,... This requirement is not met as evidenced by S1 witnessed an abuse allegation but S1 did not report it to facility director until 8 days later resulted the alleged abuser was assigned to care for R1 one more time before he/she was placed on administrative leave which posed an immediate health risk to resident in care.

Safe, healthful, comfortable accommodations

87468.1 Personal Rights of Residents in All Facilities..(a) Residents in all residential care facilities for the elderly shall..(2) To be accorded safe, healthful ... This requirement is not met as evidenced by facility staff failed to follow through with R1's pharmacy and R1's physician on 2 prescribed medications which resulted a longer delay of medication not being administered to R1 as prescribed which poses a potential health risk for residents in care.

87464 Basic Services(f)Basic services shall at a minimum include: (1) Care and supervisionThis requirement is not met as evidenced by: R1 fell at 1am, R1 pressed the call pendant for assistance and facility staff did not answer R1's call until 3 am which posed an immediately health risk for residents in care.

Maintain facility in clean, safe, sanitary condition

87303 Maintenance and Operation(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidence by: during the facility tour in the memory care unit that was provided by one of the director, LPA observed several rooms were not cleaned which poses a potential health risks for residents in care,

Facility personnel sufficiency and competence

87411 Personnel Requirements - General(a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: based on document provided, facility's care staff assignments revealed multiple open shifts and on 9/72022, there was no housekeeping staff assigned in the memory care unit which posed an immediately health risk for residents in care.

Safe, healthful, comfortable accommodations

87468.1Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe,.... The requirement is not met as evidenced by: the facility failed to have sufficient number of personnel at all times to ensure residents to be accorded safe, healthful and comfortable which poses a potential health risk for residents in care.

Regular representative updates on care

87468.1Personal Rights of Residents in All Facilities..(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights..(8) To have their representatives regularly informed by the licensee of activities related to care or services... This requirement is not met as evidenced by resident #1 sustained a change of health condition and the responsible party was not informed by the facility which poses a potential health risk for person in care.

Safe, healthful, comfortable accommodations

87468.1 Personal Rights of Residents in All Facilities..(a) Residents in all residential care facilities for the elderly shall..(2) To be accorded safe, healthful and comfortable.. This requirement is not met as evidenced by 2 residents who tested positive for COVID-19 were observed participating in activities with non affected residents in the activity room which poses an immediate health and safety risks to persons in care.

87405 Administrator - Qualifications and Duties..(b) The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee. This requirement is not met as evidenced by the administrator failed to ensure to communicate to facility staff of resident's change of health condition which poses an immediate health and safety risks to persons in care.

Report serious outbreaks and major accidents

87211 Reporting Requirements..(2) Occurrences, such as epidemic outbreaks..shall be reported within 24 hours either by telephone or facsimile to the licensing agency.. This requirement is not met as evidenced by facility failed and delayed in reporting positive COVID-19 cases to CCL which poses a potential risks to persons in care.

87506 Resident Records..(a) The licensee shall ensure..current record is maintained for each resident.b)Each resident’s record shall contain..(8)Names, address, and telephone numbers of the resident’s representative This requirement is not met as evidence by facility failed to update R1's responsible party (RP) information in R1's paper chart resulted staff contacting R1's old RP which poses a potential health and safety risk for persons in care.

Safe, healthful, comfortable accommodations

All Facilities..(a) Residents in all residential care facilities for the elderly shall have..(2)To be accorded safe, healthful and comfortable accommodations...This requirement was not met as evidenced by: The facility failed to provide an alternate accommodation(s) for the residents to take a hot shower while the circulator pump was in repair which posed potential health and safety risks to resident in care.

Personal assistance and care for required daily activities

BASIC SERVICESBasic services shall at a minimum, include personal assistance & care as needed by the resident & as indicated in the pre-admission appraisal, with those ADLs such as dressing, eating, bathing and assistance with taking medications. This requirement was not met, as staff failed to adequately assist client with eating. Licensee failed to ensure that client was provided with assistance to eat safely, as food remained in her mouth after meals. This posed a potential health and safety risk. Facility's Service Plan upon admission included total and extensive personal hygiene and feeding assistance by staff.

Safe, healthful, comfortable accommodations

PERSONAL RIGHTS OF RESIDENTS IN ALL FACILITIESResidents in all RCFEs shall have the personal right to be accorded safe, healthful and comfortable accommodations,furnishings and equipment. This requirement was not met, as former client #1 sustained a lump and hematoma on upper chest from unexplained blunt force trauma that was observed by staff on 12/29/19. Licensee failed to ensure client's right to safety, which posed a potential risk to health and safety of clients in care.