Sandhill Assisted Living Llc

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...The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents... This requirement was not met as evidenced by: Based on interviews, observations and records review, there was not enough staff member scheduled to cater to the resident’s care which poses an immediate health, safety, and personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in 2 out of 2 fire places which did not have screens, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation and interview of the administrator, the licensee did not comply with the section cited above in 2 out of 2 fences which were observed to have locks on them and are locked according to the administrator, which poses/posed a potential health, safety or personal rights risk to persons in care.

Maintain records of centrally stored medication dosages

Based on record review, the licensee did not comply with the section cited above in 4 out of 5 Centrally Stored Medication records(CSMR) which were missing a total of 12 medications,which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in 1 out of 1 boxes of supplies that shall be available to provide alternative resources during an outage, which poses an immediate health, safety or personal rights risk to persons in care.

Onsite food stock levels for nonperishables and perishables

87555 General Food Service Requirements (b) The following food service requirements shall apply: (26)S upplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by: Based on observation, there was not enough supply of canned good and 7-day non-perishable foods, which poses an immediate health, safety, and personal rights risk to persons in care.

Maintain records of centrally stored medication dosages

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...(6)When requested by the prescribing physician or the Department, a record of dosages ... This requirement is not met as evidenced by:Based on records review, R1 does not have a Medication Administration Records (MAR) log, which poses an immediate health, safety, and personal rights risk to persons in care.

Knowledge of care and supervision requirements

87405 Administrator - Qualifications and Duties (d)The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)...(1) Knowledge of the requirements for providing care and supervision appropriate to the residents. This requirement is not met as evidenced by: Based on records review, R1 moved in and caregivers were not given any information regarding the resident, which poses an immediate health, safety, and personal rights risk to persons in care.

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 dental care and provide for assistance... (4)The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on records review, there was one day where R1 was given twice the dosage of the medication and no other documentation stating that it was approved by R1s physician, which poses an immediate health, safety, and personal rights risk to persons 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... Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. ... This requirement is not met as evidenced by: Based on interviews and records review S3 was not able to help R1 due to another resident being assisted and the personnel report schedule have no specific days on when staff is scheduled, which poses an immediate health, safety, and personal rights risk to persons in care.

Regular observation and documentation of resident changes

87466 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 provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses... This requirement is not met as evidenced by: Based on interviews, the facility is not able to provide any records regarding R1s weight loss, which poses an immediate health, safety, and personal rights risk to persons in care.

87555 General Food Service Requirements (b)The following food service requirements shall apply (14) If food is prepared off the facility premises, the preparation source shall meet all applicable requirements for commercial services... This requirement is not met as evidenced by: Based on interviews, lunch is prepared in a different facility and placed in plastic containers and transported by another staff member by car, which poses an immediate health, safety, and personal rights risk to persons in care.

87465 Incidental Medical and Dental Care(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication...(2) The date and time of each contact with the physician, and the physician's directions... This requirement is not met as evidenced by: Based on records review, two medications, Lasix & Tylenol, were given to R1 with no proper documentation that it was requested from the doctor, which poses an immediate health, safety, and personal rights risk to persons in care.

Staff training in personal care activities

87411 Personnel Requirements - General(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 This requirement is not met as evidenced by: Based on interview, S1 stated that there were no logs for activities of daily living, which poses an immediate health, safety, and personal rights risk to persons in care.

On-the-job training requirements

87411 Personnel Requirements –General(d)All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance. This requirement is not met as evidenced by: Based on interviews from witnesses, there are staff that are not qualified and not trained, which poses an immediate health, safety, and personal rights risk to persons in care.

87211(a) Each licensee shall furnish... such reports... including, but not limited to, the following: (1)A written report shall be submitted to the licensing agency...(D)Any incident which threatens the welfare...or unexplained absence of any resident. This requirement is not met as evidenced by: Based on record reviews licensee did not comply with the section cited above due an incident where there is a change in condition of R1 not reported to CCLD which poses a potential health, safety or personal rights risk to persons 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 have all of the following personal rights:(2) To be accorded safe, healthful.. The requirement is not met as evidenced by facility dog presented aggression toward a family member and bit the family member which posed an immediately health risk for resident in care.

Admission agreement signing and dating deadline

Based on record review, the licensee did not comply with the section cited above due to 2 out 3 doesn’t have signature of Licensee/Administrator in the admission agreement. One resident doesn’t have signature on LIC 603 (Needs & Appraisals), another resident doesn’t have signature on LIC 621 (Personal Property & Valuables) which poses/posed a potential health, safety or personal rights risk to persons in care.

Maintain personnel records at facility location

Based on record review 2 personnel records were not readily available in the facility which poses an immediate health, safety or personal rights risk to persons in care.

Maintain required personnel records for staff

Based on record review 2 personnel records were not readily available in the facility which poses an immediate health, safety or personal rights risk to persons in care.

Health screening and fitness requirements

Based on 2 Personnel Files are not on file in the facility and is not readily available for checking which poses an immediate health and safety risk to residents..

Based on interview, a resident mentioned that he/she fell several times. No report was submitted to licnesing. The licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.

Based interview no emergency drill logs are available in the facility. Drills in the facility were done every 6 months instead of quarterly which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above because 2 staff members doesn't have valid CPR training which poses an immediate health and safety risk to residents or personal rights risk to persons in care.