Ivy Park at Rockville

1569.269 Enumerated Rights(a) Residents of a Residential Care Facility...shall have the following rights...(10) to be free from neglect, financial exploitation, involuntary seclusion...This requirement was not met as evidence by: Based on interviews and record review, the licensee did not comply in one (1) out of one (1) instance which poses a potential health safety or personal rights risk to persons in care.

87465(a)(4) Incidental Medical and Dental Care- A plan for incidental medical and dental care shall be developed by each facility. The licensee shall assist residents with self-administered medications as needed, This requirement was not met as evidenced by: In review of records, R1 and R2 both had medication error incidents occur. Per review of records, the medication staff had in-service training on medication policies in regards to medication assistance to residents in care. Information obtained support that a violation had occurred regarding both resident incidents. This is an immediate risk to residents health &safety.

87211 Reporting Requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below.. Death of any resident….Based upon record review and observation, this requirement not met as evidenced by: Death of R3 was not reported to Licensing by the facility. This poses a potential risk to the welfare of residents in care.

87465(a)(4) Incidental Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed. *** Based on statements and document reviews, this requirement has not been met as evidenced by: R1 was given wrong dose of Tramadol on 12/09; 12/15; 12/22/2025. This posed an immediate risk to the health of R1.

87303 Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Based on records and statements, this requirement not met as evidenced by: Facility has presence of bed bugs in multiple rooms in one section of facility. This poses an immediate risk to residents in care.

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: (4) To care, supervision, and services that meet their individual needs...This requirement was not met as Based on resident record review and interviews with outside parties (I1), facility did not provide appropriate supervision and assistance with R1's continence care needs. This serves as an immediate health & safety and personal rights risk to residents in care.

87465(a)(4) Incidental Medical and Dental Care:(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed.This requirement was not met as evidenced by: Based on an observation of the Medication Assessment Record (MAR) that was conducted, LPA learned that during the months of April 2023 there were gaps in the administration of medication for multiple medications which included eye drops for Resident #1. A former staff member missed the administration of eye drops on April 19-23, 2023, April 27 & 28, 2023 and April 30, 2023. An interview with the Administrator confirmed the missed medication administration for said dates. This is an immeidate Health, Safety and Personal Rights risk to the residents in care.

87303(a) Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by:Based on facility observation on March 23, 2023, LPA and Assistant Administrator observed Resident #1’s room to be smelling of incontinence and clothes on the bathroom floor. This is a potential health, safety and personal rights risk to the residents in care.

87468.1: Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.This requirement was not met as evidenced by: Based off of interviews with staff and former staff member, former staff member and Resident #1 was verbally arguing which presents an immediate health, safety and personal rights risk to the residents in care.

87468.1 Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights(11) To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This requirement was not met as evidenced by:Based on interviews that were conducted with staff and resident, a visitor was barred from visiting the facility on January 17, 2023 which poses an immeidate health, safety and personal rights risk to the residents in care.

Basic Services. Basic services shall at a minimum include: (1)Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). *** Based upon statements, this requirement has not been met as evidenced by: Staff report that residents have been left in soiled clothing and in need of bathing and changing for prolonged periods of time. ***This posed an immediate risk to the health and personal rights of residents in care.

Personnel Requirements - General. All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. *** Based upon records and statements, this requirement has not been met as evidenced by: Training records for S1 are incomplete prior to S1 assisting residents with personal activities of daily living. ***This posed a potential risk to the health and safety of residents in care.

87355 Criminal Record Clearance (e) Allindividuals subject to a criminal recordreview..prior to working...in a licensedfacility:(1)Obtain a California clearance or acriminal record exemption as required by theDepartment...This requirement was not met asevidenced by: Based on Staff Interview conducted, Licensee did not ensure that staff member (S1) had the proper background clearance needed to provide care at the facility. Thisposes an immediate health and safety risk toresidents in care.

87303(a)-Maitenance and Operation:The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by:Based on observation of the facility with Administrator on June 30, 2022, R1's room had a very strong odor of urine which presents a potential healthy, safety or personal rights risk to the resident in care.

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 including, but not limited to, an apparent life-threatening medical crisis...This requirement is not met as evidenced by: Based on Resident File Review, Facility Document Review, and Interviews conducted, the Licensee did not comply with the above regulation and did not call 911 per protocol after observing the resident experience a lot of bleeding. This poses an immediate health and safety risk to residents in care.

87555 General Food Service Requirements(b) The following food service requirements shall apply: (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement is not met as evidenced by: Based on LPA Observations and File Records reviewed, the Licensee failed to ensure Resident (R1) was following the modified diet as prescribed by their Physician. This poses an immediate health & safety risk to the residents in care.

87411 Personnel Requirements – General(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training...(1)Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Based on LPA’s observations and Interviews conducted, the Licensee did not comply with the above regulation and did not ensure that all staff that assist residents with personal activities of daily living have completed and documented training. This poses a potential health & safety risk to residents in care.

87212 Emergency Disaster Plan (c) Emergency exiting plans and telephone numbers shall be posted. This requirement is not met as evidenced by: Based on LPA’s observations, the Licensee did not comply with the above regulation and did not ensure that Facility had emergency exit plans/maps posted. This poses a potential health and safety risk to residents in care.

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2)To be accorded safe, healthful and comfortable accommodations...This requirement was not met as evidenced by: Based on LPA’s observations, the Licensee did not comply with the Department of Public Health and Department of Social Services Guidelines and Requirements related to COVID-19. LPA observed multiple individuals not wearing a mask and/or not being screened for COVID related symptoms. This poses a potential health and safety risk to residents in care.

87555 General Food Service Requirements(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents...All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by: Based on LPA observations and interviews conducted, the Licensee did not comply with the above regulation and did not ensure that food was properly stored. This poses an immediate health and safety risk to the residents in care.

87555 General Food Service Requirements: (b) The following food service requirements shall apply: (31) Dishes and utensils shall be disinfected: (A) In facilities using mechanical means, by...maintaining hot water at a minimum temperature of 170 degrees F (77 Degrees C) at the final rinse cycle of dishwashing machines... This requirement is not met as evidenced by: Based on observations and interviews, LPAs observed that Dishwasher was not maintaining proper water temperature required by regulation. This poses an immediate health, safety, and personal risk to residents in care.

87307 Personal Accommodations and Services: (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: Based on incident report review, Facility did not ensure passageways were free from obstruction. This poses a potential health and safety risk to residents in care.

87555 General Food Service Requirements(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner.This requirement has not been met based on interviews and observations showing that food service is inadequate including: food running out, food not being stored appropriately, and food portions being too small. This poses an immediate health and safety risk to residents.

87307 Personal Accommodations and Services(d) The following space and safety provisions shall apply to all facilities:(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement has not been met based on review of pictures showing that bushes were overgrown blocking the sidewalk. This poses a potential health and safety risk to residents in care.

1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) 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 has not been met as evidence by: Based on observation and interviews, LPA observed that staff are not assisting residents in a timely manner which poses a potential health & safety risk to residents in care.

1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) 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 was not met as evidenced by: Resident R1 sustained several falls, R1 was observed to require additional needs and services for their safety along with staff escort to meals. This is an immediate risk to the health and safety of residents in care

87218(a) Theft and Loss(a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153. This requirement was not met as evidenced by: Resident R1 had several clothing items missing and after moving out, family found several items of clothing that did not belong to R1 along with a wheelchair that belong to another resident. This is a potential risk to the personal rights of residents in careResidents property,

Based on LPA observation, the licensee did not comply with the section cited above in 4 out of 4 sharps (razor blades & pair of scissors) accessible to residents with dementia, which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPA observation, the licensee did not comply with the section cited above in 3 out of 6 inspected faucets accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPA, observation, the licensee did not comply with the section cited above in 4 out of 4 over the counter medications accessible to residents with dementia, which poses an immediate health, safety or personal rights risk to persons in care.

1569.269(a)(21) Residents of residential care facilities for the elderly shall have all of the following rights:… To have prompt access to.. records. Photocopied records shall be promptly provided, not to exceed two business days.....*** Based on interviews and records reviewed, the licensee did provide records requested by R1’s responsible party on 5/28/21. This poses a potential violation of R1’s personal rights.

87411(d)(5) Personnel Requirements General-(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (5) Knowledge necessary in order to recognize early signs of illness and the need for professional help. This requirement is not met as evidenced by: Based on LPA record review & interviews conducted, facility did not meet the needs of R1, staff failed to recognize & report early signs of illness- to meet the care needs of R1. This poses an Immediate Health and Safety risk to residents in care.

87303(i)(1)(A)Maintenance and Operation (i) Facilities shall have signal systems which shall meet the following criteria:(1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall:A) Operate from each resident's living unit. This requirement was not met, as evidenced by: investigation revealed Resident R1's call button did not work at times. This is a potential Health and Safety risk to residents in care.