South County Retirement Home Inc.

87411 General Personnel Requirement (b)All persons who supervise employees or who supervise or care for residents shall be at least eighteen (18) years of age. This requirment is not met as evidenced by: Based on record review, LIC/ADM did not ensure that S2 was at least 18 years of age at time of hire S2 on 10/08/2024. S2s CA ID/DL confirms S2 is under age18. S2 works partime at the facility, which pose/poses an immediate health, safety & personal rights risks to persons in care.

Record centrally stored prescriptions and refill data

Based on record review, the licensee did not comply with the section cited above. Based on a review of R1-R5's centrally stored medication record, R1-R5's medication start dates is not listed for all 5 residents. While reviewing R2's medications, LPA observed Medication M1 & M2 were not listed on R2's Centrally Stored Medication record. This poses/posed a potential health, safety or personal rights risk to persons in care.

Regular representative updates on care

87468.1 Personal Rights of Residents in All Facilities (a)(8) 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 evicenced by; Based on investigation, R1’s responsible party and/or Case Manager was not immediately informed when R1 had a fall and current health condition before he/she was admitted to the hospital.

Right to sufficient care and qualified staff

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(4) To care, supervision, and services that meet their individual needs and are delivered by staff ... to meet their needs.This requirement was not met as evidenced by Based on investigation, R1 did not receive immediate medical assistance after R1 fell and subsequently verbalized having pain. Staff did not adhere to facility’s protocol on medical emergency by calling 9-1-1

Knowledge of care and supervision requirements

87405 Administrator - Qualifications and Duties (d)(1) Knowledge of the requirements for providing care and supervision appropriate to the residents. This requirement was not met as evidenced by: Based on investigation, ADM was not aware of R1’s fall because according to ADM he/she does not read staff notes on the weekend. ADM also did not inform R1’s CM of R1’s fall and R1 being a fall risk was not addressed in 2019 when he/she had his/her initial fall at the facility.

Update reappraisal at required intervals

87463 Reappraisals (a) The pre admission appraisal shall be updated, in writing as frequently as necessary to note significant changes ...document changes in the resident's physical, medical, mental, and social condition. This requirement was not met as evidenced by: Based on investigation, R1 was a fall risk with an associated fall history. R1 had a fall in 2019. A review of R1’s LIC624 Appraisal Needs and Services Plan (ANS) dated Feburary 2, 2019, the facility did not update R1’s ANS to address fall prevention.

1569.69(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements. this requirment was not met at evidenced by; Based on Interview & record review. S1 admitted assiting with medication without medication training. Medication training records did not show S1 recive medication training in 2021 and 2022. ADM also confirmed this. This poses a potential health , safety and personal rights risk to residents.

1569.69(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements. this requirment was not met at evidenced by; Based on Interview & record review. S1 admitted assiting with medication without medication training. Medication training records did not show S1 recive medication training in 2021 and 2022. ADM also confirmed this. This poses a potential health , safety and personal rights risk to residents.

Facility must safeguard entrusted cash and valuables

87217(b) Safeguards for Resident Cash, Personal property and valuables: (b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. This requirement is not met evidence by: During investigation on 5/19 and 6/7, staff and residents were interviewed and acknowledged missing items such as clothing. LPAs and LPM observed on 5/19 and 6/7 residents' clothing with no name or labels in the laundry room. This pose a potential health, safety and personal rights risk.

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. Maintenance shall include ... procedures for the safety and well-being of residents, employees and visitors. This requirement is not being met evidenced by: Based on observation and interviews, multiple areas of cigarette buds found on floor, broken chairs and appliances at the front area, multiple areas with swarms of flies, including front door& smoking area which poses an immediate threat to the Health, Safety and Personal Rights risk to the persons in care.

Keep prescriptions in original containers

Incidental Medical and Dental Care (h)(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met by: Based on interview and observation, the administrator did not comply by storing resident medication in small brown envelopes 4 days in advance which poses a potential Health, Safety, or Personal Rights risk to persons in care

Maintain facility in clean, safe, sanitary condition

87303(a) Maintenance and Operation: (a) The facility shall be in clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of mainteance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met by: Based on observation of the covered patio at the backyard has swarm of at approximately 40 flies above the 10 seated residents who were smoking. The outside table observed with an empty can soda, tables with melted cheese and a peeled orange fruit which poses an immediate Health, Safety, or Personal Rights risk to persons in care.

Store centrally held medications in locked secure place

Incidental Medical and Dental Care (h)(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met by: Based on interview and observation, the administrator did not comply by storing resident medication in a kitchen cabinet which does not have locking capabilities poses a potential Health, Safety, or Personal Rights risk to persons in care

Update reappraisal at required intervals

87463 - Reappraisals - (a) The pre-admission appraisal shall be updated... to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical... condition. This requirement was not met as evidenced by: Based on interviews and records review, the facility did not update R1's care plan when it became evident that R1 was a fall risk, resulting in fracture. This posed an immediate threat to the health and safety of residents in care

Call 9-1-1 for imminent health threats

87465 - Incidental Medical and Dental Care - (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health... This requirement was not met as evidenced by: Based on interviews and records review, the facility did not contact 911 until two days after R1's injury that resulted in fracture. This posed an immediate threat to the health and safety of residents in care.