Sage Mountain Senior Living

(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. Based interviews and record review, the licensee did not comply with the section cited above when they did not inform R1’s responsible party of a fall with injury, which posed a potential health, safety and personal rights risk to residents in care.

Provide resident hot water for personal care

Based on observation, the licensee did not comply with the section cited above in five out of ten restrooms that measured above the required 105-120 F temperature which poses an immediate health, safety or personal rights risk to persons in care.

Right to sufficient care and qualified staff

87468.2(a)(4)residents…shall have all of the following personal rights: 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 is not met as evidence by: Based on staff interviews, the licensee did not comply with the section cited above when staff did not assist R1 to the restroom and paramedics were called to assist R1 which posed an immediate personal rights risk to residents in care.

Right to sufficient care and qualified staff

87468.2(a)(4)residents…shall have all of the following personal rights: 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 is not met as evidence by: Based on records review, the licensee did not comply with the section cited above as Staff did not respond to R1’s call for assistance in a timely manner, which posed a potential health and safety risk to residents in care.

Fire approval and staff access to unlock systems

Based on observation, the licensee did not comply with the section cited above as medication was observed in room #112, #239, #304, and #249, and per the residents LIC602 cannot administer medications which poses an immediate health, and safety risk to persons in care.

Ensure hazardous items are locked and not unattended

Based on observation, the licensee did not comply with the section cited above in two of 10 resident restrooms had cleaning solutions which poses an immediate health and safety risk to persons in care.

Maintain facility in clean, safe, sanitary condition

Based on observation, the licensee did not comply with the section cited above in three of ten rooms observed as the floors of rooms 249, 233 and 238 were not sanitary which posed a potential health and safety or personal rights risk to persons in care.

Ensure hazardous items are locked and not unattended

87309 Storage Space(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidence by: Based on observation the licensee did not comply with the section cited above in one carts with cleaning supplies was left unattended which poses an immediate health and safety risk to persons in care.

Maintain cleanliness and prevent incontinence odors

87625(b)(3) Managed Incontinence (b) ...the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.This requirement was not met as evidenced by: Based on interviews, and file review the licensee did not comply with the section cited above when Staff did not respond timely and ensure R1 was kept dry, which posed an immediate health and safety/personal rights risk to residents in care.

Comply with all admission agreement terms

87507(f) Admission Agreements: The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section by not ensuring R1 and/or R1's authorized person recieved credit/refund for days R1 was not in the community which posed a potential health, safety, and personal rights risk for residents in care.

87465(j) In all facilities licensed for sixteen (16) persons or more, one or more employees shall be designated as having primary responsibility for assuring that each resident receives needed first aid and needed emergency medical services… This requirement is not met as evidenced by: Based on interviews & records review, the licensee did not comply with the section cited above. Facility staff did not seek medical assistance for R1 on 12/30/22 and 01/05/23, which posed an immediate health and safety risk to residents in care.

Right to sufficient care and qualified staff

87468.2(a)(4)residents…shall have all of the following personal rights: 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 is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above when staff did not respond to R1’s call for assistance and did not seek timely medical treatment for R1 on two occasions, which posed an immediate health and safety risk to residents in care.

This is an amended report. This page intentionally left blank

Licensee responsibility for records confidentiality

87506(c)(1) The licensee shall be responsible for storing active and inactive records...The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative. This requirement was not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above when the facility did not make complete records available to the resident or representative, which poses a potential health, safety or personal rights risk to persons in care.

Facility must safeguard entrusted cash and valuables

87217(b) Safeguards for Resident Cash, Personal Property, and Valuables 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. Based on interviews S2 admiited to taking R1's incontinence supplies which posed a potential health and safety risk to residents in care.

Right to sufficient care and qualified staff

Residents…have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers...and competency to meet their needs. This requirement is not met as evidenced by: Based on interviews conducted, the licensee did not comply with the above cited section, as the licensee did not ensure resident’s call buttons were responded to timely which posed a potential health and safety risk to residents in care.

Theft and loss. (c) Documentation of lost property with a value of twenty-five dollars or more within 72 hours of the discovery of the loss or theft, (d) A written inventory is established … items brought into or removed shall be added to or deleted from the inventory. This requirement is not met as evidenced by: Based on interview, the licensee failed to make reasonable efforts to safeguard a resident’s property, as the facility lost clothing items, which poses a potential personal rights risk to residents in care.

Right to sufficient care and qualified staff

87468.2(a)In addition to the rights listed in Section 87468.1 (4) 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 is not met as evidenced by: Based on interviews & records review, the licensee did not comply with the section cited when there was not sufficient, competent staff to provide timely first aid assistance to R1, resulting in death by choking, which posed an immediate health and safety risks to

First aid training requirements

87411 Personnel Requirements (c)All RCFE staff who assist residents... (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 record review, the licensee failed to comply with the section cited above as S2’s first aid certification expired in February 2022, and S2 did not have a current certificate during the incident on 01/24/2023 which posed a health and safety risk to residents in care.

Right to confidential records and approved disclosure

87468.2 (a) In addition to the rights listed in Section 87468.1,....(4)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 is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above as staff failed to respond timely to an emergent situation pertaining to R1 which posed an immediate health and safety concern to R1 in care.

Keep bath, laundry and kitchen floors clean

Based on observation and interview, the licensee did not comply with the section cited above as in bedroom 319 did not have a comfortable temperature for the resident, based observation room #241 had a strong odor emitting from the bathroom and carpet next the closet which poses a potential health and safety risk to persons in care.

Based on observation, the licensee did not comply with the section cited above as the faciltiy did not have a supply of emergency food and water which poses a potential health and safety risk to persons in care.

Keep bathing and hygiene facilities in operating condition

Based on observation, the licensee did not comply with the section cited above as sink in bedroom #241 was not draining and retaining the water which poses a potential health and safety risk to persons in care.

§1569.625 (b)(1) The department shall.. require staff members of RCFE's who assist residents with personal ADL's to receive appropriate training. This training shall consist of 40 hours of training. (2) In addition..training requirements shall also include an additional 20 hours annually. This requirement is not met as evidence by: Based on record review, the licensee failed to comply with the section above as three out of four caregiver files did not have proof of required initial training and/or annual training which poses a potential risk to residents in care.

1569.69 (b) Each employee who received training and passed.. (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period.This requirement is not met as evidence by: Based on record review, the licensee failed to comply with the section cited above as three med-techs did not have proof of annual medication training which poses a potential health and safety risk to residents in care.

First aid training requirements

87411 Personnel Requirements - General (c)(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 record review, the licensee failed to comply with the section cited above as six out of six files reviewed did not have proof of first aid training which poses a potential health and safety risk to residents in care.

87705 Care of Persons with Dementia (c)(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, 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 is not met as evidence by:Based on record review, the licensee failed to comply with the section cited above as one resident with dementia had a medical assessment older than one year which poses a potential health and safety risk to residents in care.

Assist residents with self-administered medication

87465 Incidental Medical and Dental Care (a) (4) The licensee shall assist residents with self-administered medications as needed.This requirement is not met as evidenced by: Based on record review and interview, the licensee failed to comply with the section cited above R1 received their medication late and R1 did not receive their medication due it not being ordered timely which poses an immediate health risk to R1 in care.

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..needs and are delivered by staff that are sufficient in numbers, qualifications, and competency... This requirement is not met as evidenced by: Based on interviews and record review, the licensee failed to comply with the section cited above as three residents (R2, R4, R6) had pendent call wait times in excess of 20 minutes which poses an immediate health and safety risk to residents in care.

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..needs and are delivered by staff that are sufficient in numbers, qualifications, and competency... This requirement is not met as evidenced by: Based on interview and record review, the licensee failed to comply with the section cited above as R1 had approximately 46 pendent response time in excess of 20 minutes during a one month time period which is an immediate personal rights and health and safety risk to R1 in care.

Personal rights of residents in all facilities

87468.1 Personal Rights of Residents in All Facilities (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.This requirement is not met as evidenced by: Based on interviews and observation, the licensee did not comply with the section cited, as a photo of an alcoholic beverage was taken in the memory care and staff posted on social media they were drinking while at work which poses an immediate H&S risk to residents in care.

Obtain required California clearance or exemption

87355 Criminal Record Clearance(e) All individuals subject to a criminal record review pursuant to...1569.17(b) shall prior to working.... in a licensed facility:(2) Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement is not met as evidence by: Based on interview and record review the licensee failed to comply with the section cited above as Staff #1 (S1) has worked at the facility since August 2022 and their criminal record clearance has not been transferred to the facility which poses an immediate health and safety risk to residents.

Care and supervision as defined by statute and rules

87464 Basic Services (f) 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).This requirement is not met as evidenced by: Based on interview, observation, and record review the licensee did not comply with the above cited section, as facility staff were aware R1 was a fall risk, R1 fell multiple times, and the falls weren't reported, which posed an immediate health and safety risk to residents in care.

Assist residents with self-administered medication

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed.This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section, as the facility administered R1's medications without food, as it was ordered, which posed an immediate health risk to residents in care.

87555 General Food Service Requirements (b) The following food service requirements shall apply: (5) Meals shall consist of an appropriate variety of foods and shall be planned with consideration for...food habits of residents.This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section, as food provided at the facility was not aligned with R1's medical needs and personal food choices, so R1 did not eat, which posed an immediate health & personal rights risk to residents in care.

Regular observation and documentation of resident changes

87466 Observation of the ResidentThe licensee shall ensure that residents are regularly observed for changes....that appropriate assistance is provided when such observation reveals unmet needs...This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above section, as Resident #1 (R1) had a change of contition, and the facility did not intervene nor report, which poses an immediate health and safety risk to residents in care.

Document required significant condition changes

87463 Reappraisals (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 interview and record review, the licensee did not comply with the above section, as R1 had significant weight loss, decreased oral intake, and increased falls and no reappraisal was completed, which poses an immediate health and safety risk to residents in care.

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.This requirement is not met as evidence by: Based on observation, the licensee failed to comply with the section cited above, as the delayed egress auditory alarm located in the memory care front desk/medication room was not operational which poses a potential health and safety risk to residents in care.

87211 Reporting Requirements a) Each licensee shall furnish to the licensing agency such reports as the Department may require, ... D)Any incident which threatens the welfare, safety or health of any resident, such as.... This requirement is not met as evidenced by: Based on record review and interview, the licensee failed to comply with the section cited above, as the facility did not submit written incident reports to CCLD pertaining to Resident #1 (R1) which poses a potential personal rights risk to residents in care.

Food quality controls and rejected damaged goods

87555 General Food Service Requirements (b)(8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.This following requirement was not met as evidenced by: Based on observation, the licensee failed to comply with the section cited above as the LPA observed 8 food items with use by dates of 6/13/22, 7/14/22, 7/23/22 and 7/24/22, and multiple items with best by dates of 10/17/21, 3/30/22, 7/11/22, 7/14/22 and 7/23/22, which poses an immediate health and personal rights risk to residents in care.

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 provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.This requirement is not met as evidenced by: Based on observation and interview, the licensee failed to comply with the section cited above as a phone number was not posted on the locked entry door for after hour guests, emergencies, deliveries, etc. to alert staff of their presence which poses a potential health, safety, and personal rights risk to residents in care.

Facility personnel sufficiency and competence

87411 Personnel Requirements - General(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.This requirement is not met as evidenced by: Based on record review and interview, the licensee failed to comply with the section cited above as S1 allowed R2 to leave the secured memory care unit unassisted resulting in S2 eloping from the facility which is an immediate health and safety risk to residents in care.

1569.312(a) Basic service requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. Licensee did not provide adequate care and supervision to R1 which attributed to R1 sustaining pressure injuries not reported and not cared for, which posed an immediate health and safety risk to residents in care.

Obtain required California clearance or exemption

87355 Criminal Record Clearance(e) All individuals subject to a criminal record review pursuant to... 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by: Based on record review and interview, the licensee failed to comply with the section cited above as two staff (S1 &S2) are not associated to the facility which poses an immediate health and safety concern to residents in care.

Safe, healthful, comfortable accommodations

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, furnishings and equipment.This requirement is not met as evidenced by: Based on observation and interviews, the licensee failed to comply with the section cited above as the delayed egress system is not loud enough for staff to her audibly inside all areas of the memory care and staff were observed to not be using iPods which would alert them of the egress system which poses an immediate safety risk to residents in care.

Fire approval and staff access to unlock systems

Based on observation, the licensee did not comply with the section cited above as the laundry room with bleach and other cleaning supplies was unlocked which poses an immediate health, safety or personal rights risk to persons in care.

Obtain required California clearance or exemption

Based on record review, the licensee did not comply with the section cited above as one staff's criminal record clearance was not transferred to the facility which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation and interview, the licensee did not comply with the section cited above as the facility had no bottled water or any other emergency water 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: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 LPAs observation, the facility failed to keep R1's bedrrom clean, safe and sanitary which poses a potential safety risk to residents in care.

Maintain facility in clean, safe, sanitary condition

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 LPAs observation, the facility failed to keep R1's bedrrom clean, safe and sanitary which poses a potential safety risk to residents in care.