Lynne & Roy M Frank Residences

Regular observation and documentation of resident changes

OBSERVATION OF THE RESIDENTThe 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... 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 client #1 did not receive timely medical intervention when pressure ulcers were observed, which poses a potential health, safety or personal rights risk to clients.

This training shall consist of 40 hours... A staff member shall complete 20 hours, including 6 hours specific to dementia care, as required by subdivision (a) of Section 1569.626 ...before working independently with residents. The remaining 20 hours shall include 6 specific to dementia care and shall be completed within the first four weeks of employment. This requirement was not met, as there is no evidence that staff #2 and #3--who were hired 4/23 and 12/22 respectively--received at least 12 hours of dementia specific training, which posed a potential health, safety or personal rights risk to clients.

...training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626...This requirement was not met, as there is no documentation that staff #1, who was hired 5/22, received at least 8 hours of dementia specific training. Licensee failed to ensure that staff received required annual dementia training, which posed a potential health, safety, or personal rights risk to clients in care.

Regular representative updates on care

PERSONAL RIGHTS OF RESIDENTS IN ALL FACILITIESResidents in all RCFEs shall have...the following personal rights:To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. This requirement was not met, as responsible parties of client #1 were not notified when staff observed pressure injuries on client #1. Licensee failed to ensure that responsible parties of client #1 received timely report that pressure injuries were observed, which posed a potential health, safety or personal rights risk to clients.

Any person who is not a conservatee and is entering a locked or secured perimeter facility pursuant to this section shall sign a statement of voluntary entry. The facility shall retain the original statement and shall send a copy of the statement to the department. This requirement was not met, as client #1 was not conserved and did not sign a statement of voluntary entry into facility's memory care unit. Licensee failed to obtain written consent from client #1 upon admission to memory care unit with delayed egress, which posed a potential health, safety or personal rights risk to clients 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. This requirement is not met as evidenced by the delayed egress exit door for the memory care unit was malfunctioned and R1 eloped the unit throught this exit and was found on the 5th floor roof top which poses an immediately health and safety risk for residents in care.

87705 Care of Persons with Dementia (c) Licensees who accept..residents with dementia shall be responsible for ensuring the following:.(3) In addition to the on-the-job training requirements..(A) Dementia care including, but not limited to, the environment,.. This requirement is not met as evidenced by after R1 eloped the unit through the delayed egress door, the alarm went off and the staff did not checked the exit/stairwell that was led to the roof top where R1 was found poses a potential health and safety risks to resident in care.

Care and supervision as defined by statute and rules

87464(f)(1) Basic Services(f)- Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Codesection 1569.2(c). This requirement was not met as evidenced by: there was no care and supervision provided when R2 and R3 were watching TV in the TV room which posed an immediate health and safety risks to resident in care.

Protection from punishment and intimidation

87468.1 Personal Rights...(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(3) To be free from punishment, humiliation, intimidation, abuse.... This requirement was not met as evidenced by: the facility failed to ensure R1 was free from punishment and abuse as R1 was handled roughly by a former staff who grabbed R1 and R1 sustained an injury which posed an immediate health and safety risks to resident in care.