Bristolwood Home

87205(a)The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves. This requirement is not met as evidenced by:Based on interview, Licensee admitted that there was no general supervision over the affairs of the licensed facility which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.

87415(a) The following persons providing night supervision from l0:00 p.m. to 6:00 a.m. (1) In facilities caring for less than sixteen (16) residents, there shall be a qualified person on call on the premises.This requirement is not met as evidenced by: Based on review of LIC 500, Licensee admitted that on-call night staff is not awake to provide night supervision from 10:00pm to 6:00am, which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.

87625 (b) (1) Ensuring that residents who can benefit from scheduled toileting are assisted or reminded to go to the bathroom at regular intervals rather than being diapered.This requirement is not met as evidenced by: Based on interview, Licensee and Administrator stated resident R1 was placed in diaper at night instead of scheduled toileting at night with the on-call night staff which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.

87465 Incidental Medical and Dental Care (h)(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...This requirement is not met as evidenced by: Based on record review, observation and interview, 4 out of 4 resident files did not contain Centrally Stored Medication Log/Record which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.

87608 Postural Supports (a)(3) A 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 evidenced by: Based on record review, obserbation and interview, 2 out of 4 residents using half-bed rails for mobility did not have signed written physician's order in resident's file which poses/posed a potential health, safety or personal rights risk to persons in care.

87465 Incidental Medical and Dental Care (a) (4) The licensee shall assist residents with self-administered medications as needed.This requirement is not met as evidenced by: Based on record review and interview, the facility staff did not have R1's medication #1 refill at the facility during the time of inspection and medication was to be administered at bedtime which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.

1569.695 Emergency Plans (c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios.This requirement is not met as evidenced by: Based on record review and interview, the ADM conducted last disaster drill on 1/2/2024 which poses/posed a potential health, safety or personal rights risk to persons in care.

87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.This requirement is not met as evidenced by: Based on record review, interview, and observation, ADM did not ensure resident medication was available to administer and medicaton log was not completed, chemicals were accessible to residents with Dementia, resident room/bedrooms are not in sanitary conditions, fire drills are not conducted every

87411 Personnel Requirements - General (a) Facility personnel shall at all times be... competent to provide the services necessary to meet resident needs...This requirement is not met as evidenced by: Based on record review and interview, R1's medication #1 was not refilled and not located at the facility and R1's medication #1 order is to be administered at bedtime which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia:(2) ...toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.This requirement is not met as evidenced by: Based on observation and interview, 2 laundry detergent containers and 5 containters of paint were located near the laundry mahcine in the backyard accessible to residents which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.

W&IC 15655 (a)(1) long-term care facilities, ... shall provide to all staff being trained a written copy of the reporting requirements and a written notification of the staff's confidentiality rights as specified in Section 15633.This requirement is not met as evidenced by: Based on record review and interview, 2 out of 2 staff files reviewed did not contain signed copy of the SOC341 and ADM was not aware of regulation which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.

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: Based on observation and record review, bathroom in resident room #5 had yellow stains on the toliet seat/bowel and dark brown/black stains on the floor near the base of the toliet which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.

87465 Incidental Medical and Dental Care (a)(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.This requirement is not met as evidenced by: Based on interview and record review, facility staff delayed seeking medical attention for R1 after having a fall at 3am and was in pain &was transported to the hospital at 9:05am which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.

87468.2(a)(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 requirement is not met as evidenced by: Based on interview,on-call night staff did not respond to R1's call for help; off-duty staff heard and prompted to assist R1 which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.