Lexington Assisted Living

Assist residents with self-administered medication

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 records reviewed, the licensee did not comply with the section cited above. R1's medications were not given as prescribed; staff did not properly document medication administration or start dates, which posed an immediate health and safety risk to residents in care.

Obtain baseline medical assessment before resident admission

87458(a) Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above. R1’s medical assessment was missing physician signature, which posed a potential health and safety risk to residents in care.

Incidental Medical and Dental Care(j) In all facilities licensed for 16 persons or more, one or more employees shall be designated…for assisting residents as needed with self-administration of medications... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above. R1’s medication was not cross referenced with the prescribed medication list which caused R1 to not receive one of the seizure medications for 10 days, which resulted in a seizure and hospitalization, which posed an immediate health and safety risk to residents in care.

Assist residents with self-administered medication

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 interviews and records review, the licensee did not comply with the section cited above. Staff did not dispense prescribed medication to R1, which resulted in a seizure and required medical attention, which posed an immediate health and safety risk to residents in care.

Licensee reports required by licensing agency

Each licensee shall furnish to ... licensing ...such reports as the Department may require, (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence......This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above when staff did not notify person responsible for resident within seven days of the fall, which poses a potential health and safety risk to residents in care.

Maintain records of centrally stored medication dosages

Based on record review, the licensee did not comply with the section cited above in one out of three residents' medications reviewed and missing the medication dose start date, which poses an immediate health, safety or personal rights risk to persons in care.

Provide resident hot water for personal care

Based on observation, the licensee did not comply with the section cited above in one out of one residents' bathroom faucets tested for hot water temperature which measured 121.6 degrees F, which poses a potential health, safety or personal rights risk to persons in care.

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency...(1) A written report... within seven days of the occurrence...(D) Any incident which threatens the welfare, safety or health of any resident... This requirement was not met as evidenced by: Based on record review, the licensee did not comply with the section cited above as CCL did not receive an incident report when R1 suffered a medical emergency on or about 8/13/2024, which poses a potential health, safety, or personal rights risks to residents in care.

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency...(1) A written report... within seven days of the occurrence... (A) Death of any resident from any cause regardless of where the death occurred...This requirement was not met as evidienced by: Based on record review, the licensee did not comply with the section cited above as CCL did not receive a death report regarding R1's passing on or about 8/20/2024, which poses a potential health, safety, or personal rights risks to residents in care.

Personal assistance and care for required daily activities

87464 Basic Services (f) (4) Personal assistance and care as needed by the resident and as indicated in the preadmission appraisal, with those activities of daily living such as dressing, eating, bathing...This requirement is not met as evidenced by: Based on interview and record review, R1 required assistance with 2 showers per week and according to documents reviewed, R1 did not reveive a shower for 8 days following move in, which poses a potential health and personal rights risk to persons 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 interview and record review, the licensee did not comply with the above cited section, as R1 moved into the facility on 01/22/2023 and medications were not documented as administered until 01/24/2023, which posed a potential health and safety risk to persons in care.

A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information... ...(e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident.This requirement is not met as evidenced by:

Assist residents with self-administered medication

(a)A plan for incidental medical and dental care shall be developed by each facility... and provide for assistance in obtaining such care(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on records review and interviews, the licensee did not comply with the section cited above. Facility staff failed to provide R1’s Buprenorphine, Ticagrelor, and aspirin as prescribed, which posed an immediate health and safety risk to residents in care.

Right to sufficient care and qualified staff

(a) In addition to the rights listed in Section 87468.1. Residents shall have all of the following personal rights: (4) To care, supervision, and services that 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 records review and interviews, the licensee did not comply with the section cited above. Facility staff failed to respond to R1 in a timely manner, which posed an immediate health and safety risk to residents in care.

Based on record review, the licensee did not comply with the section cited above as R1’s medication’s prescription number on bottle did not match that on the CSMDR, which poses a potential health, safety, or personal rights risks to residents in care.

87464(f)(4) Basic Services. Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission ..., with those activities of daily living such as dressing,bathing... This requirement is not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above as R1's hygiene needs were not met, which poses a potential health and safety risk to residents in care.

Update reappraisal at required intervals

87463(a)-Reappraisals. The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes ... changes in the resident's physical, medical, mental, and social condition… This requirement is not met as evidenced by: Based on interviews and record review, licensee did not comply with the section cited above as R1's reappraisal was not updated to reflect change of condition, which poses a potential health and safety risk to residents in care.

87705(c)(4) Care of Persons with Dementia (c) Licensees who accept... residents with dementia shall be responsible ...There is an adequate number of direct care staff to support each resident’s ...safety. This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the above section by not having sufficient staff to ensure R2 did not leave the facility unassisted per physician report, which poses an immediate health and safety risk to resident in care.

Right to sufficient care and qualified staff

Residents shall have all of the following personal rights: To care, supervision, and services that meet theirindividual needs and are delivered by staff… to meet their needs.This requirement is not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above, as R1 was not properly cared for and supervised as R1 was diagnosed with a fracture of left pubis and physical condition changed...

A written report shall be submitted to the licensing agency ... within seven days of the occurrence: Any incident which threatens the welfare, safety, or health of any resident.This requirement is not met as evidenced by: Based on interviews and documents reviewed, the licensee did not comply with the section cited above, as the facility had a scabies outbreak in October 2020 and did not report it to CCLD until February 2021, which poses a potential health & safety risk to residents in care.

Assist residents with self-administered medication

87465(a)(4) Incidental Medical and Dental Care. 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 in the section cited above for two out of two residents (R1 and R2), which poses an immediate health and safety risk to residents in care.

1569.269 Enumerated rights; severability (a)(30) To keep, have access to, and use their own personal possessions, including toilet articles, and to keep and be allowed to spend their own money, unless limited by statute or regulation.This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above as R1 did not have access to their hearing aids which poses a potential personal rights risk to persons in care.

Maintain cleanliness and prevent incontinence odors

87625 Managed Incontinence(b)(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above as R1 was observed to be left soiled for an extended period of time which poses a potential health and personal rights risk to persons in care.

Assist residents with self-administered medication

87465 Incidental Medical and Dental Care Services(a)(4) The licensee shall assist residents with self-administered medications as needed.This requirement is not met as evidenced by: Based on interviews and medication review, the licensee did not comply with the section cited above as R1 did not get their medication as prescribed which poses an immediate health risk to persons in care.

87555 General Food Service Requirements(b)(1) Where all food is provided by the facility arrangements shall be made so that each resident has available at least three meals per day. Exceptions may be allowed on weekends and holidays providing the total daily food needs are met. Not more than fifteen...This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above as breakfast and lunch was not made available to R1 on 2/19/22 which poses a potential health and personal rights risk to persons in care.

Fire approval and staff access to unlock systems

87705 Care of Persons with Dementia (f)(2) The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.This requirement is not met as evidenced by Based on LPA's observations, the licensee did not comply with the section cited above as disinfectants and toxic items were observed accessible to residents which poses an immediate health risk to persons in care.

1569.269 Enumerated rights; severability (a)(10) Residents of residential care facilities for the elderly shall have all of the following rights: To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above as residents were handled roughly by staff which poses an immediate health, safety and personal rights risk to persons in care.

1569.269 Enumerated rights; severability (a)(10) Residents of residential care facilities for the elderly shall have all of the following rights: To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above by ensuring residents personal rights are not being violated by R1 which poses an immediate safety and personal rights risk to persons in care.

Fire approval and staff access to unlock systems

87705 Care of Persons with Dementia (f)(2) The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.This requirement is not met as evidenced by Based on LPA's observations, the licensee did not comply with the section cited above as toxic items were observed accessible to residents which poses an immediate health risk to persons in care.

87705(e) Care of Persons with Dementia. Swimming pools and other bodies of water shall be fenced and in compliance with state and local building codes.This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above, as the gate leading to the swimming pool was not locked, which poses an immediate health and safety risk to persons in care.

Fire approval and staff access to unlock systems

87705 Care of Persons with Dementia (f)(2) The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.This requirement is not met as evidenced by Based on LPA's observations, the licensee did not comply with the section cited above as dishwashing liquid was observed accessible to residents which poses an immediate health risk to persons 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. Based on interviews, the licensee did not comply with the section cited above as residents were not administered their medications as prescribed which poses a potential health and personal rights risk to persons in care.

Obtain required California clearance or exemption

87355 Criminal Record Clearance. (e)(2) 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: Request a transfer of a criminal record clearance as specified in Section 87355(c) or...This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above as the licensee did not ensure that S1 was associated prior to allowing S1 to work, which poses an immediate safety risk to persons in care.

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 interviews and record review, the licensee did not comply with the section cited above as residents were not being changed timely which poses a potential health and personal rights risk to persons in care.

Notify agency before locking doors or gates

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).This requirement is not met as evidenced by: Based on LPA's observation, the licensee did not comply with the section cited above as scissors were accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.

Report serious outbreaks and major accidents

87211 Reporting Requirements(a)(2) Occurrences, such as epidemic outbreaks, poisonings…which threaten the welfare, safety or health of residents, personnel…shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.This requirement is not met as evidenced by Based on interviews and record review, the licensee did not comply with the section cited above as the licensee did not report COVID positive residents to Community Care Licensing and Ventura County Public Health which poses a potential health and personal rights risk to persons in care.

Store centrally held medications in locked secure place

87465 Incidental Medical and Dental Care Services (h)(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.This requirement is not met as evidenced by: Based on LPA's observations, the licensee did not comply with the section cited above as R2's medications were observed accessible to residents which poses an immediate health and safety risk to persons in care.

Update reappraisal at required intervals

87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition….This requirement was not met as evidenced by: Based on documentation review, the licensee did not comply with the section cited above as R1’s Needs and Services Plan was not updated to reflect a change of condition which poses a potential health and safety risk to persons in care.

Obtain required California clearance or exemption

87355 Criminal Record Clearance. (e)(2) 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: Request a transfer of a criminal record clearance as specified in Section 87355(c) or...This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above as the licensee did not ensure that S1 was associated prior to allowing S1 to work, which poses an immediate safety 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 evidenced by: Based on LPA’s observations, the licensee did not comply with the section cited above as disinfectants, cleaning solutions and other items which could pose a danger were accessible to residents which posed an immediate health and safety risk to persons in care.

1569.312 Basic services requirements (a) 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 as they failed to provide adequate care and supervision to R1 which attributed to R1 sustaining multiple injuries due to falls, which posed an immediate health and safety risk to persons in care.

1569.69 Employees assisting residents with self-administration of medication; training requirements (b) Each employee who received training and passed the examination required…, 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 evidenced by: Based on interview and record review, the licensee did not comply with the section cited above as S1 did not complete the annual medication training which poses a potential health risk to persons in care

87312 Motor Vehicles Used in Transporting Residents Only drivers licensed for the type of vehicle operated shall be permitted to transport residents. The rated seating capacity... Any vehicle used by the facility to transport residents shall be maintained in a safe operating condition.This requirement is not met as evidenced by: Based on LPA's observations and interviews, the licensee did not comply with the section cited above as the facility van is not maintained in a safe operating condition which poses a potential safety and personal rights risk to persons in care.

Notify agency before locking doors or gates

Based on observation, the licensee did not comply with the section cited above as pliers, screwdrivers and scissors were accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.

87219 Planned Activities (f) Planned Activities. In facilities licensed for fifty (50) persons or more, one staff member shall have full-time responsibility to organize, conduct and evaluate planned activities, and shall be given such staff assistance as…This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above as the facility did not have an Activity Director which posed a potential personal rights risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above as 6 out of 70 total residents did not have a current Physician's Report which poses a potential health, safety or personal rights risk to persons in care.

1569.69 Employees assisting residents with self-administration of medication; training requirements (a)(1) In facilities licensed to… This training shall consist of 16 hours of hands-on shadowing training, which shall be completed prior to assisting with the self- administration of medications, and 8 hours…This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above as S1 did not complete medication training prior to assisting residents with medications which poses a potential health risk to persons in care.

Fire approval and staff access to unlock systems

Based on observation, the licensee did not comply with the section cited above as over the counter and prescription bottles, laundry soap and dish soap were found in an unlocked room which poses an immediate health, safety or personal rights risk to persons 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 interviews, the licensee did not comply with the section cited above as the facilities internet was not working properly which posed a potential personal rights risk to persons in care.

Obtain required California clearance or exemption

87355 Criminal Record Clearance. (e)(2) 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: Request a transfer of a criminal record clearance as specified in Section 87355(c) or...This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above as the licensee did not ensure that S1 was associated prior to allowing S1 to work, which poses an immediate safety risk to residents in care.

Fire approval and staff access to unlock systems

87705 Care of Persons with Dementia (f)(2) The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.This requirement is not met as evidenced by: Based on LPA's observations, the licensee did not comply with the section cited above as Over-the-counter-medication, vitamins, and toxic substances were observed accessible to residents which poses an immediate health and safety risk to persons in care.

Store centrally held medications in locked secure place

87465 Incidental Medical and Dental Care Services (h)(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.This requirement is not met as evidenced by: Based on LPA's observations, the licensee did not comply with the section cited above as resident medications were observed accessible to residents which poses an immediate health and safety risk to persons in care.

Fire approval and staff access to unlock systems

87705 Care of Persons with Dementia (f)(2) The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.This requirement is not met as evidenced by: Based on LPA's observations and record review, the licensee did not comply with the section cited above as medication, alcohol, cleaning supplies and disinfectants were observed accessible to residents which poses an immediate safety risk to persons in care.

Store centrally held medications in locked secure place

87465 Incidental Medical and Dental Care Services (h)(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.This requirement is not met as evidenced by: Based on LPA's observations, the licensee did not comply with the section cited above as R1's medications were observed accessible to other residents which poses an immediate safety risk to persons in care.

Facility maintenance and healthful environment

87307(d)(2) Personal Accommodations and Services The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.This requirement was not met as evidenced by: Based on LPAs interviews with residents and staff, the facility failed to provide a safe and healthful environment, as water was not available from 10pm to 4am on May 20th, which poses as a potential health and safety risk to residents in care.

87468 Personal Rights – (a)Residents in residential care facilities for the elderly shall have personal rights... as applicable to the facility.This requirement was not met as evidenced by: Based on LPAs interviews with residents and staff, the facility failed to provide advanced notice to residents that water was going to be shut off on May 20th, between 10pm – 4am, which poses as potential health and safety risk to residents 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 evidenced by: Based on observation, during the facility tour, a storage closet containing gallons of paint was left open and accessible to residents, which poses a potential health and safety risk to residents in care.