A Peace of Home

Based on observation, the licensee did not comply with the section cited above as the water temperature was measured in the resident bathrooms to be between 129.3 and 133.3 degrees Fahrenheit which poses an immediate health risk to persons in care.

Based on observation and interview, the licensee did not comply with the section cited above as two fire extinguishers were not serviced annually and two (2) unapproved bedrooms were constructed in the facility garage without proper building permits or fire clearance which poses an immediate safety risk to persons in care.

The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. 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 the Administrator did not demonstrarte sufficient knowledge, and qualifications as an Administrator, admitting & retaining R1 with a prohitivive health condition which poses an immideate

87615(a)(1) Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained... (1) Stage 3 and 4 pressure injuries. 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 had a left foot unstageable pressure ulcer and a coccyx stage 3 pressure ulcer and R1 was not admitted to hospice care at that time, which posed an immediate health risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above when there was an unexplainable overcount of four (4) of R1’s prescribed medications and an undercount of one (1) of R1’s medications which poses an immediate health and safety risk to residents in care.

87466 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... ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person… This requirement is not met as evidenced by:Based on interviews, R1’s resident representative/physician was not notified when R1 had a change of condition, which posed a potential health and safety risk to residents in care.

87465 Incidental Medical and Dental Care (a)(1) (a) (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above as staff did not obtain timely medical attention for R1 when R1 was discovered with multiple bruises and unable to walk on their own, and was later diagnosed with a fractured left femur, which posed an immediate health and safety risk to residents in care.

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…The licensing agency may require any facility to provide additional staff whenever it determines through...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 facility has one caregiver from 7:30 pm to 7:30 am which poses a potential safety and personal rights risk to persons in care.

Based on LPA's observation, the licensee did not comply with the section cited above as the hot water temperature in a resident bathroom read at 141.3 degrees F. which poses an immediate health and safety risk to persons in care.

Based on LPA's observations, the licensee did not comply with the section cited above as R1's medication was observed in the kitchen refrigerator accessible to residents which poses an immediate health risk to persons in care.

Based on LPA's observations, the licensee did not comply with the section cited above as the facility did not have a one week supply of nonperishable vegetables and fruit which poses a potential health and personal rights risk to persons in care.

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 substances were observed throughout the facility accessible to residents which posed an immediate health risk to persons 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...This requirement is not met as evidence by: Based on record review, the licensee did not comply with the section cited above in 3 out of 4 resident records which poses a potential health and safety risk to persons in care.

87608 Postural Supports (a)(5)(B) Under no circumstances shall postural supports include tying, depriving...Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.This requirement is not met as evidence by: Based on our observations and record review, the licensee did not comply with the section cited above as R1's hospice care plan does not specify the need for full bed rails which poses a potential safety risk to persons in care.

87705 Care of Persons with Dementia(f)(1) The following shall be stored inaccessible to residents with dementia: 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 observations, the licensee did not comply with the section cited above as scissors, hammer, screwdriver and power drill was observed accessible to residents which posed an immediate health and safety risk to persons in care.