Hanover Guest Home

87705 Care of Persons with Dementia (c)(5) Each resident with dementia shall have an annual medical assessment ... and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.This requirement was not met as evidenced by; Based on record review and interview, both R2 and R3's needs and services plans have not been updated annually. Both R2 and R3 have neurocognitive impairment. This poses/posed a potential health, safety or personal rights risk to persons in care.

87111 Continuation of License Under Emergency Conditions (b) In the event of a licensee's death...(1) notify the Department by the next working day of the licensee’s deathThis was not met as evidenced by: Based on interview and record review, the ADM did not inform the Department of the death of the Licensee by the next working day. ADM stated the Licensee died in 2015, which poses an immediate health, safety and personal rights risk to persons in care.

Certified administrator requirements and substitute coverage

87405 Administrator - Qualifications and Duties(a) The administrator shall.. permit adequate attention to the management and administration of the facility as specified in this section.This was not met as evidenced by: ADM acknowleges non-payment of civil penalties. ADM states she is unable to pay due to her 'budget' and not having enough residents, which poses an immediate health, safety, and personal rights risks to persons in care.

First aid training requirements

87411 Personnel Requirements(c)(1) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training...Staff providing care shall receive appropriate training in first aid.This requirement is not met as evidenced by: Based on interview, observation and record review, ADM did not ensure 9 out of 9 staff received initial or annual training, and first aid training, which poses an immediate health, safety and personal rights risk to persons in care.

(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 record review and interview, ADM did not ensure that the facility is conducting emergency drills for 2025, which poses an immediate health, safety and personal rights to persons in care.

Obtain baseline medical assessment before resident admission

87458 Medical Assessment (a) Prior to a person's acceptance as a resident... a medical assessment, signed by a licensed medical professional... made within the last year, to be kept in the resident's record.This was not met as evidenced by Based on record review and interview, R1's record did not contain a medical assessment, which poses an immediate health, safety and personal rights risk to persons in care.

87355 Criminal Record Clearance(c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another.This requirement is not met as evidenced by: Based on interview, observation and record review, the ADM did not ensure S8 and S9 were associated prior to working in the facility which poses an immediate health, safety and personal rights risk to persons in care.

Passageways and stairways kept clear

87307 Personal Accommodations and Services (d)(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.This requirement is not met as evidenced by: Based on interviews and observation, the facility was locking the exit next to the dinning area, room 9, and front entrance of the facility. ADM stated R2 has an exit seeking behavior. ADM acknowledged this was a form of restraint. This poses an immediate health, safety or personal rights risk to persons in care.

Maintain separate complete record for each resident

This is an amended report for visit date 8/27/2024.Based on observation, interview, and record review, the licensee did not ensure 5 residents CSMDRs were maintained and 1 resident's file did not contain a physician's report which poses/posed a potential health, safety or personal rights risk to persons in care.

This is an amended report for visit date 8/27/2024Based on observation, interview and record review, the licensee did not ensure at least 1 staff on duty and on the premises has CPR and First Aid training. LPAs observed 2 staff scheduled on shift during visit that did not have CPR and First Aid certification which poses an immediate health, safety or personal rights risk to persons in care.

This is an amended report for visit date 8/27/2024.Based on observation, interview and record review, the licensee did not ensure drills were conducted quartely which poses/posed a potential health, safety or personal rights risk to persons in care.

Passageways and stairways kept clear

This is an amended report for visit date 8/27/2024.Based on observation, interview and record review, the licensee did not ensure that sliding exit doors tracks were free of obstruction. LPAs observed a pole and a wooden plank obstructing the sliding exit door tracks which poses an immediate health, safety or personal rights risk to persons in care.

Document required staff training and orientation

This is an amended report 8/27/2024Based on observation, interview and record review, the licensee did not ensure to provide 5 staff with 10 hours of initial and 20 hours of annual training on topics covered in Section 87707 which poses/posed a potential health, safety or personal rights risk to persons in care.

Document behavioral expression and related causes

This is an amended report for visit date 8/27/2024.Based on observation, interview, and record review, the licensee did not ensure 5 resident's appraisal/needs and services plan was reviewed and signed by the resident and/or resident's representative which poses/posed a potential health, safety or personal rights risk to persons in care.

This is an amended report for visit date 8/27/2024.Based on observation, interview and record review, the licensee did not ensure hygiene items were inaccessible to a Dementia resident who is at risk if allowed access to hygiene items based on physcian's report. LPAs observed mouthwash, shampoo, conditioner, and toothpaste on a dresser in Dementia resident's room which poses an immediate health, safety or personal rights risk to persons in care.

Maintain physician order documentation in resident record

This is an amended report for visit date 8/27/2024.Based on observation, interview, and record review, the licensee did not ensure 2 residents files contained a physician's order for half bed rails which poses/posed a potential health, safety or personal rights risk to persons in care.

Obtain required California clearance or exemption

87355 Criminal Record Clearance (e)(2) Request a transfer of a criminal record clearance as specified in Section 87355(c) Based on interview, observation and record review S2 works in the facility without association which poses an immediate health, safety and personal rights risk to persons in care.

Address and clearance obligations before facility work

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility.This requirement was not met as evidenced by; Based on interview, observation and record review S1 was working in the facility without obtaining a criminal record background clearance which poses an immediate health, safety and personal rights risk to persons in care.

87705 Care of Persons with Dementia (c)(5) Each resident with dementia shall have an annual medical assessment ... and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement was not met as evidenced by; Based on record review and interview, both R1 and R2's physicians reports and needs and services plans have not been updated annually. Both R1 and R2 have dementia. This poses/posed a potential health, safety or personal rights risk to persons in care.

Required administrator qualifications listed in this subsection

Administrator Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)....This requirement is not met as evidenced by: Based on the result of todays visit, the ADM did not conform to applicable laws, rules and regulations. Staff S1 was working at the facility without finger print cleareance. Residents R1 and R2 did not have an updated needs and services plan and physicans report.