Routine inspection (multi-day)·August 29, 2024

Citations

10 citations recorded^*CCLD

• 87608(a)(3)Type B

  Maintain physician order documentation in resident record

  87608(a)(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record.This requirement is not met as evidenced by: Based on observation, interview, and record review 2 out of 2 residents did not have a physician's order on file for the use of half bed rails which poses/posed a potential health, safety or personal rights risk to persons in care.

• 15655Type B

  §15655 Training on elder and dependent adult abuse;...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, the licensee did not comply with the section cited above in 2 out of 2 staff files did not contain SOC341A which poses/posed a potential health, safety or personal rights risk to persons in care.

• 1569.6959(c)Type B

  (c) A facility shall conduct a drill at least quarterly for each shift....Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.This requirement is not met as evidenced by: Based on observation and record review, the facility staff could not provide documentation on the disaster drills conducted at the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.

• 80075(k)(7)Type B

  (k)(7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above wherein 1 out of 2 resident’s medications which are centrally stored were not recorded and maintained poses an immediate health, safety or personal rights risk to persons in care.

• 87203Type B

  Maintain facilities for fire and panic safety

  87203 Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.This requirement is not met as evidenced by: Based on interview and observation, fire extinguisher inspected in the facility were last serviced on 09/27/2019 and a new fire extinguisher was purchased last year but no receipt was provided which poses/posed a potential health, safety or personal rights risk to persons in care.

• 87405(d)(2)Type B

  Conformance with applicable laws and regulations

  (d)The administrator shall have the qualifications...If the licensee is also the administrator, all requirements for an administrator shall apply. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidenced by: Based on observation, interview &record review, the Licensee/Administrator did not comply with section cited above by not maintaining staff and resident files, maintaining fire extinguisher, maintaining records of disaster drill which poses/ posed a potential health, safety or

• 87458Type B

  87458 (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year.This requirement was not met as evidenced by: Based on observation and record review, resident R3's file did not contain LIC 602 Physician's Report which poses/posed a potential health, safety or personal rights risk to persons in care.

• 87463(b)Type B

  Document required significant condition changes

  87463(b) The licensee shall immediately bring any such changes to the attention of the resident's physician and his family or responsible person.This requirement is not met as evidenced by: Based on record review and interview, 2 out of 2 resident files did not contain Appraisal/Needs and Services Plan and Individual Service Plan signed by resident and/or responsible party which poses/posed a potential health, safety or personal rights risk to persons in care.

• 87466Type B

  Regular observation and documentation of resident changes

  87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes … such as unusual weight gains or losses … the licensee shall ensure that such changes are documented …This requirement is not met as evidenced by Based on record review, ADM did not keep a record of resident’s weight gains or losses to regularly observe any changes, which pose/poses a potential health risk to persons in care.

• 87468(b)(1)(A)Type B

  Signed rights acknowledgement in resident record

  87486 Personal Rights (b)(1)(A) The licensee shall have each resident and the resident's representative sign a copy of these rights, and the signed copy shall be included in the resident's record.This requirement is not met as evidenced by: Based on interview and record review the licensee did not comply with the section cited above in 2 out of 2 resident files did not contain a signed copy of Personal Rights of Residents in All Facilities which poses a potential health, safety or personal rights risk to persons in care.