Moldaw Family Residences at 899 Charleston

87468.1(a)(3) Personal Rights: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met as evidenced by: Licensee did not ensure that staff S1 did not handle residents R1 and R2 in a rough manner by pulling on their blankets and pants, which poses an immediate safety risk to residents in care.

87616(a) Exceptions for Health Conditions: As specified in Section 87209, Program Flexibility, the licensee may submit a written exception request if he/she agrees that the resident has a prohibited and/or restrictive health condition but believes that the intent of the law can be met through alternative means. This requirement was not met as evidenced by: the licensee did not submit an exception request for R1’s Foley catheter, which posed a serious health risk to residents in care.

Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.This requirement was not met as evidenced by: Facility staff failed to bring to the attention of R1’s physician and family representative when staff observed R1 had a penile discharge from 12/29/19 through 01/3/2020, which posed a serious health risk to residents in care.

General Requirements for Restricted Health Conditions(c) The licensee shall document any significant occurrences that result in changes in the resident’s physical, mental and/or functional capabilities and immediately report these changes to the resident’s physician and authorized representative. This requirement was not met as evidenced by: facility staff failed to immediately report the changes to R1’s physical condition of possible blood in urine to R1’s physician/home health and authorized representative. Staff observed blood in urine as early as 12/29/19 but facility did not report until 1/5/2020 when authorized representative noticed the change during visit which resulted in serious bodily injury to R1.