Santa Maria Terrace

87465 Incidental Medical and Dental Care (a) (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met based on interviews and records reviewed, licensee did not comply with the section cited above when Staff gave R1 a medication at 9:55am, but order and interview with medical professional stated “bedtime”, which posed a potential health and safety risk to the resident in care.

Additional Personal Rights of Residents ... in privately operated residential care facilities... shall have... 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.

87464 Basic Services (f)(4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications... This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply in the section sited above when staff did not properly assist resident with showers or have a system to make up missed showers which posed a potential health and safety risk to residents in care.

87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility... (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on interviews, the licensee did not comply in the section sited above when staff did not properly assist residents with medications and issued the incorrect dose which posed an immediate health and safety risk to residents in care.

87507 Admission Agreement (C) Any fee that is charged prior to or after admission, shall be clearly specified.This requirement was not met as evidenced by: Based on interviews, the licensee did not comply in the section sited above when staff did took 4 months to agree on a refunded shower amount, which posed a potential health and safety risk to residents in care.

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 was not met as evidenced by: Based on interviews, the licensee did not comply in the section sited above when staff were not sufficient in numbers at all times to meet resident needs, which posed a potential health and safety risk to residents in care.

Based on record review, the licensee did not comply with the section cited above in two staff were not associated to the facility, which poses an immediate health and safety risk to persons in care.

87465(h)(6) Incidental Medical and Dental Care (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: (C) The drug name, strength and quantity. This requirment was met as evidenced by: Based on record review, the licensee did not comply with the section cited above when the facility did not assure the centrally stored medications had the correct quantity, which poses a potential health and safety risk to persons in care.

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed...(4) The licensee shall assist residents with self administered medications as needed.This requirement was not met as evidenced by: Based on record review, the licensee did not comply with the section cited above when the facility did not follow doctors orders and properly assist resident with medication, which poses an immediate health and safety risk to persons in care.

87506(c)(1) The licensee shall be responsible for storing active and inactive records...The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative. This requirement was not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above when the facility did not make records available to the resident or representative, which poses a potential health, safety or personal rights risk to persons in care.

87211(a)(1)(D) Reporting Requirements (a) Each licensee shall furnish... the following: (1)A written report shall be submitted to the licensing agency...within seven days of the occurrence of any of the events specified in (A) through (D) below.... This requirment was not met as evidenced by: Based on record review, the licensee did not comply with the section cited above when the facility did not submit a written report within 7 days, which poses a potential health, safety or personal rights risk to persons in care.

87211(a)(2) Reporting Requirements(a) Each licensee shall furnish....reports ...(2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents...within 24 hours either by telephone or fax... This requirment was not met as evidenced by: Based on record review, the licensee did not comply with the section cited above when the facility did not report an epidemic outbreak within 24 hours, which poses a potential health, safety or personal rights risk to persons in care.

87507(g)(5)(E)(2)(c) Admission Agreements. A refund of at least 40 percent of the preadmission fee in excess of $500 shall be provided if the resident leaves the facility for any reason during the third month of residency. This requirement was not met as evidenced by:Based on interviews and record review, the licensee did not comply with the above cited section when R1 was not given a 40 percent refund, which posed a potentail health and safety risk to residents in care.

87468.1(a)(16) Personal Rights. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To receive or reject medical care or other services.This requirement was not met as evidcned by: Based on interviews, the licensee did not meet the section cited above as resident was not given the right to reject medical care, which poses a potential health, safety, and personal rights risk to residents in care.

87464(d) Basic Services. …If a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal ...either directly or through outside resources. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the above cited section when R1's needs were not met, which posed a potential health and safety risk to residents in care.

Based on record review, the licensee did not comply with the section cited above in 2 out of 40 staff were not associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.

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 specified in (A) through (D) below...This requirement was not met as evidenced by: Based on record review, the licensee did not ensure incident reports were sent within 7 days of the occurrence on multiple occasions, which posed a potential health, safety, and personal rights risk to residents in care.

87307(a)(3) Personal Accommodations and Services. Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. This requirement is not met as evidenced by: Based on interviews, the licensee did not ensure residents’ incontinence care products were readily available to each resident when needed, which poses a potential health and safety risk to residents in care.

87625(b)(3) Managed Incontinence...the licensee shall be responsible for the following: Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.This requirement is not met as evidenced by: Based on record review, interviews and photographs, the licensee did not ensure residents’ incontinence was properly managed, which poses an immediate health and safety risk to residents in care.

87464(d) Basic Services. …If a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal...either directly or through outside resources.This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the above cited section when R1 did not receive a shower for 22 days after moving into the facility, which posed a potential health and safety risk to residents in care.

87411(a) Personnel Requirements- Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not ensure there was sufficient staff to meet resident needs which posed an immediate health and safety risk to clients in care

87303(e)(6) Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times.This requirement was not met as evidenced by: Based on interviews and observation the licensee did not ensure R1’s room was clean and sanitary upon move in which posed a potential health and safety risk to clients in care.

87303(e) Maintenance and Operation: Water supplies and plumbing fixtures shall be maintained.This requirement was not met as evidenced by: Based on interviews and observation, the licensee did not ensure toilets and bathrooms were properly sealed, allowing water to leak to the apartment bellow, which posed an immediate health and safety risk to clients in care.

87411(a) Personnel Requirements. 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 interview and record review, the licensee did not comply with the above section when they had inadequate staff to respond to call buttons, which posed an immediate health and safety risk to residents in care.

87465(c)(2) Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced By: Based on medication review, the licensee failed to ensure medications were not given as prescribed for resident 1. (R1) which poses an immediate health and safety risk to residents in care.

87465(c)(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not ensure that resident received the prescribed medication

Based on record review and observation of the individual being present at the facility, the licensee did not comply with the section cited above in 1 count, which poses an immediate health, safety or personal rights risk to persons in care.