Portola Gardens

Report specified resident events within seven days

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 incident which threatens the welfare, safety or health of any resident.This requirement is not met as evidenced by: Based on document review, facility did not submit a written report to the Department for fall occurrences of R1 and R2 and alleged physical abuse on R3, which is a potential health, safety, or personal rights risk to persons in care.

Maintain physician order documentation in resident record

Based on record review, the licensee did not comply with the section cited above in 4 out of 4 residents did not have physician orders for bed rails in the resident files, which poses/posed a potential health, safety or personal rights risk to persons in care.

Dignity in personal relationships

Personal Rights requirement: Residents in all residential care facilities for the elderly shall…be accorded dignity in their personal relationships with staff, residents

Reappraisals requirement: The reappraisal shall document significant changes in…Behavioral expression…that may result in harm to self or others. This requirement was not met, as evidenced by file reviews and interviews, which revealed that the client was not reappraised after documented incidents of exhibiting harm to staffs. This violation poses an immediate health and safety risk to residents in care.

Personal rights requirement: To care, supervision, and services that meet their individual needsThis requirement was not met, as evidenced by file reviews and interviews revealed that the client’s care, supervision and services were not adjusted to prevent harm to other client, despite documented incidents of client exhibiting harm toward staffs. This violation poses an immediate health and safety risk to residents in care.

Dignity in personal relationships

Personal Rights requirement: Residents in all residential care facilities for the elderly shall…be accorded dignity in their personal relationships with staff This requirement is not met as evidenced by: Based on video evidence showing two staffs engaging in inappropriate conduct inside the resident’s room. This serious violation poses an immediate health and safety risk to residents in care.

Maintain physician order documentation in resident record

Based on record review, the licensee did not comply with the section cited above in 4 out of 10 residnets did not have MD orders for haf bed rails in their files, which poses/posed a potential health, safety or personal rights risk to persons in care.

PERSONAL ACCOMMODATIONS & SERVICESIndividual privacy shall be provided in all toilet, bath and shower areas. This requirement was not met, as commodes were observed on 4/16/24 in shared rooms 103, 107, 116. This poses a potential health, safety, or personal rights risk to clients in care.

Every RCFE shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The Dept. shall account for the presence of these detectors during inspections. This requirement was not met, as carbon monoxide detectors were not present on 4/16/24, per administrator. This poses a potential health and safety risk for clients in care.

Maintain physician order documentation in resident record

POSTURAL SUPPORTSA written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met, as MD orders are not maintained for half bed rails for 2 clients, which poses a potential health, safety or personal rights risk to clients. Clients #2 & #8 are missing MD orders for half bed rails. On 4/16/24, half bed rails observed for 20 beds, which require MD orders on file.

Based on observation of nonperishable food supply, the licensee did not comply with the section cited above, as there is an insufficient 7-day canned food supply, which poses a potential health, safety or personal rights risk to persons in care.Seven-day food supply consists of 2 large cans of ravioli, 23 cans of pineapple, 22 cans of sauerkraut.

§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 resident interviewed, 4/5 residents interviewed indicated that when they tried to press their call pendants/buttons, staff will either not respond or not respond in a timely manner which poses an immediate health and safety 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...Violation of this regulation is evidenced by: Based on observations and interviews conducted, it was acknowledged that the electric hospital bed was broken. According to the Director of Wellness, she had the Maintenance Director check the bed and found that the electical outlet was not working.

Obtain baseline medical assessment before resident admission

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 the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.Violation of this regulation is evidenced by: Based on record review, facility failed to maintain an up to adte physician's report for R1 which poses a potential health and safety risk for residents in care.

Obtain required California clearance or exemption

Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement was not met as evidenced by: Based on records review, licensee failed to request a transfer of criminal record clearance for S1 which poses an immediate health and safety risk to clients in care.On 03/25/2022, LPA confirmed with LVN that S1 is still employed with facility and is providing care and supervision to residents.

BASIC SERVICESBasic services shall at a minimum include:Care and supervision, meaning the responsibility for... ongoing assistance with ADLs, without which the resident’s physical health, mental health, safety, or welfare would be endangered.This requirement was not met, as client #1 eloped from facility without staff knowledge today. Because Licensee failed to ensure that client was supervised, he left the premises, which posed a immediate risk to his health, safety and welfare.

Update reappraisal at required intervals

Reappraisal: 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. This requirement is not met as Licensee failed to appraise R1 after several unusual incidents; 12/8/21, 9/7/21,11/20/20, and 3/28/20, some of which required medical intervention. Licensee failed to ensure that appraisal and care plan accurately reflects his needs. This poses a potential health and safety risk to client.

Report serious outbreaks and major accidents

Reporting; Occurrences, such as...or major accidents which threaten the welfare, safety or health of residents...shall be reported within 24 hours... to the licensing agency This requirement was not met as R1 left the facility on 12/8/21 without staff knowledge and Licensee failed to report this to CCLD as required. Incident report was submitted following LPA's reqeust and contact with facility LVN on 12/10/21. This posed a potention health, safety, and personal rights risk to clients care.