CARSON SENIOR ASSISTED LIVING

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(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: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. During the facility inspection, LPA identified rooms 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 203, 216, 220, and 221 that had damaged or missing window screens. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/02/2026 Plan of Correction Licensee will replace the missing screens and repair screens. The facility will inspect all resident room window screens to ensure they are present, clean, and in good repair. A written statement of completion and photos of the repaired screen will be submitted to CCLD by 06/02/26. The Administrator will also train staff on reporting damaged or missing screens to management.

Official classification

Type A

Official code

87631(a)(1)

Regulation authority

CCR

What the official deficiency says

87631 Healing Wounds- (a)The licensee shall be permitted to accept or retain a resident who has a healing wound under the following circumstances: (1)When care is performed by or under the supervision of an appropriately skilled professional. This requirement was not met as evidenced by: Based interviews and record review, the facility did not ensure that (R1)'s pressure injuries were cared for by an appropriately skilled professional. This violation poses an immediate health and safety risk to residents in care.

Official plan of correction

Administrator and staff shall take state approved vendored training on 87631 Healing wounds. Submit vendor name, address, vendor number and phone number with date of training. Plan of correction must be submitted to ernand.dabuet@dss.ca.gov by 03/18/26.

Deadline recorded: Mar 18, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

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 when such observation reveals unmet needs... This requirement was not met as evidenced by: Based on interviews and record review, the administrator did not take appropriate action or assistance timely medical attention for (R1) when noticeable changes were observed in (R1)’s condition. This violation poses an immediate health and safety risk to residents in care.

Official plan of correction

Administrator and staff shall take state approved vendored training recognizing resident's change in health condition. Submit vendor name, address, vendor number and phone number with date of training. Plan of correction must be submitted to ernand.dabuet@dss.ca.gov by 03/18/26.

Deadline recorded: Mar 18, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87631(a)(1)

Regulation authority

CCR

What the official deficiency says

87631 Healing Wounds- (a)The licensee shall be permitted to accept or retain a resident who has a healing wound under the following circumstances: (1)When care is performed by or under the supervision of an appropriately skilled professional. This requirement was not met as evidenced by: Based interviews and record review, the facility did not ensure that (R1)s pressure injuries were cared for by an appropriately skilled professional, which caused an immediate health and safety risk to (R1).

Official plan of correction

Administrator and staff shall take state approved vendored training on 87631 Healing wounds. Submit vendor name, address, vendor number and phone number with date of training. Plan of correction must be submitted to ernand.dabuet@dss.ca.gov by 03/16/26.

Deadline recorded: Mar 16, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

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 when such observation reveals unmet needs... This requirement was not met as evidenced by: Based on interviews and record review, the administrator did not take appropriate action or assistance timely medical attention for R1 when noticeable changes were observed in R1’s condition, which caused an immediate health and safety risk to R1.

Official plan of correction

Administrator and staff shall take state approved vendored training on 87631 Healing wounds. Submit vendor name, address, vendor number and phone number with date of training. Plan of correction must be submitted to ernand.dabuet@dss.ca.gov by 03/16/26.

Deadline recorded: Mar 16, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(b)(2)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including:.(2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. This requirement was not met as evidence by: Based on LPA interviews conducted and record reviews, the Licensee failed to ensure to address R1's history of wandering behavior and went missing, while unsupervised by facility staff. This violation poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee agrees that a Plan of Correction will be submitted to CCLD by 11/19/24, Administrator agreed that Arbor Hall staff will be advised to be on " high alert " meaning being more vigilant in monitoring all access exit door and windows while a Plan of Correction is developed by POC date 11/19/21 to the licensing office.

Deadline recorded: Nov 19, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466 Observation of Resident -The licensee to ensure that residents are regularly observed for changes in physical, mental, emotional, and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. Based on LPA interviews conducted and record reviews, the Licensee was aware of of R1's history of wandering behavior failed to ensure proper supervision was in in place. This violation poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee shall have a written plan to ensure that in addition to the resident's needs and services plan a specific plan is drafted for each resident's change in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. The plan must be submitted by POC date 12/02/24 to the licensing office.

Deadline recorded: Dec 2, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) 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 interviews and record review, (S1) failed to carry out the duties and responsiblites and left medication unattended and accessible to (R1) with dementia. This violation poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee/Administrator agreed to comply with and review Title 22 Regulation, Section “Care of Persons with Dementia " and will ensure all staff complete Medication Training. A sign-in sheet with all staff who completed the training is due by POC date to LPA Dabuet via email: ernand.dabuet@dss.ca.gov

Deadline recorded: Sep 7, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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), the licensee did not comply with the section cited above. LPA identified a non-working HVAC system for room #5, #11, #165 and the main dining room.immediate This violation] which poses a potential health and safety or personal rights risk to persons in care.

Official plan of correction

Licensee/Administrator will need to replace or repair the HVAC for room #5, #11, #165 and main dining area. The licensee will provide portable heaters for rooms mentioned above until services are completed. Proof of correction must be sent to LPA by email in a video at ernand.dabuet@dss.ca.gov by 02/18/24.

Deadline recorded: Feb 18, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(2)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on (observation), the licensee did not comply with the section cited above. LPA observed non-working HVAC system for room #5, #11, #165 and the main dining room Facility failed to provide a healthful and comfortale environment. This violation which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee/Administrator will need to provide working portable heaters for rooms #5, #11 and main dining room. Proof of correction must be sent to LPA by email in a video at ernand.dabuet@dss.ca.gov by 01/25/24.

Deadline recorded: Jan 25, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(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), the licensee did not comply with the section cited above. LPA identified a non-working carbon monoxide, dead pest, and dangling unattached camera. This violation] which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

LIcensee/Administrator will need to replace/repair the carbon monoxide, clear dead pest from fumigation, and attached camera to ceiling bracket. Proof of correction must be sent to LPA by email in a video at ernand.dabuet@dss.ca.gov by 06/16/23. Corrected during visit on 06/15/23 *Repeat Violation Immediate $250.00*

Deadline recorded: Jun 16, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)(1)(e)(6)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. (1) Floor surfaces in bath...shall be maintained in clean, sanitary, and ordorless condition. (e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition....equipment shall be provided in facilities acoomodating physically handicappedand/or a non-ambulatory residents... Based on [(observation), the licensee did not comply with the section cited above. LPA identified a rusted leaky faucet, stained floor/sink, and loose toilet flusher. This violation] which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

LIcensee/Administrator will need repair leaky rusted faucet, remove stained in sink and floor and repair toilet flush for room #203. Proof of correction must be sent to LPA by email in a video at ernand.dabuet@dss.ca.gov by 06/29/23 Amended: This report serves as an amendment to clarify subsections missing on second citation. It does not supersedes the complaint investigation findings reflected on report created on 06/15/23.

Deadline recorded: Jun 29, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(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: Deficient Practice Statement Based on [(observation), the licensee did not comply with the section cited above. LPA identified a non-working smoke detector missing outside the activity room in memory care. This violation] which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/15/2023 Plan of Correction LIcensee/Administrator will need to replace/repair the smoke detector. All smoke dectectors must be in working condition. Proof of correction must be sent to LPA by email in a video at ernand.dabuet@dss.ca.gov by 04/15/23.

Official classification

Type B

Official code

87555(29)

Regulation authority

CCR

What the official deficiency says

(29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) the licensee did not comply with the section cited above. LPA identified kitchen stove rear and front burners not working condition and required a match to operate. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/13/2023 Plan of Correction Licensee/Administrator will ensure that all food service equipment are in working condition and have the rear and front stove burners repaired. Proof of correction must be sent to LPA with a repair/invoice receipt by email at ernand.dabuet@dss.ca.gov by 06/13/23.

Official classification

Type A

Official code

87468.2(a)(8)

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights... residents in privately operated residential care facilities for the elderly shall have...(8) To be free from neglect... involuntary seclusion... and verbal, mental, physical, or sexual abuse. This requirement is not met as evidenced by: Based on observations and interviews, the licensee did not comply with the section cited above. The facility confined, restricted, and isolated resident #1 in a locked room. This violation poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee/Administrator will adhere to Title 22 Sec. 87468.2 regarding personal right of residents and will certify written statement the regulations have been review and understood and will train staff on personal rights. Certification will be provided to CCLD by the POC due date: 11/07/22. *IMMEDIATE CIVIL PENALTY*

Deadline recorded: Nov 7, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes... and that appropriate assistance is provided... when such observation reveals unmet needs. When changes such as... deterioration of mental ability or a physical health condition... are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician... This requirement is not met as evidenced by: Based on observations, record reviews and interviews, the faciltiy failed to address resident #1 required higher level of care and supervison. This violation poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee/Administrator will adhere to Title 22 Sec. 87466 regarding observation of the resident and will certify written statement the regulations have been review and understood and will train staff on regularly observation on residents conditions. Certification will be provided to CCLD by the POC due date: 11/07/22. *REPEAT CIVIL PENALTY*

Deadline recorded: Nov 7, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(B)(D)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department... (B) Any serious injury... occurring while the resident is under facility supervision. (D) Any incident which threatens the welfare, safety or health of any resident... This requirement is not met as evidenced by: Based on record reviews and interviews, the licensee did not comply with the section cited above. The facility failed to submit written report serveral falls and injuries of resident #1. This violation poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee/Administrator will review Title 22 Sec. 87211 and agreed to provide training to staff pertaining to CCLD reporting Requirements. Licensee will provide to LPA a sign-in sheet with staff signatures as proof that staff attended training by the POC due date: 11/18/22.

Deadline recorded: Nov 18, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87608(5)

Regulation authority

CCR

What the official deficiency says

87608 Postural Supports (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. This requirement is not met as evidenced by: Based on observation and interviews, the licensee did not comply with the section cited above. The facility tied a sheet to restraint resident #1 in wheelchair. This violation poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee/Administrator will review Title 22 Sec. 87608 and agreed to provide training to staff pertaining to CCLD postural supports. Licensee will provide to LPA a sign-in sheet with staff signatures as proof that staff attended training by the POC due date: 11/18/22.

Deadline recorded: Nov 18, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(5)(A)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (5) Each resident with dementia shall have an annual medical assessment...Medical Assessment, and a reappraisal done at least annually... (A) When any medical assessment, appraisal, or observation indicates... changed, corresponding changes shall be made in the care and supervision provided to that resident. This requirement is not met as evidenced by: Based on record reviews, and interviews, the facility failed to conduct an annual medical, appraisal, and needs services for resident #1 who was diagnosed with dementia. This violation poses/posed a potential health, safety, or personal rights risk to persons in care.

Official plan of correction

Licensee/Administrator will review Title 22 Sec. 87705 and agreed to review and understand the requirements in this section. Licensee will provide to LPA a written statement as proof that this section was review and will comply by POC due date: 11/12/22.

Deadline recorded: Nov 18, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

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 is not met as evidenced by: Based on record reviews, and interviews, the facility failed to ensure the safety of resident #1 of falls and injuries. The faciltiy did not have a fall plan in place. This violation poses/posed a potential health, safety, or personal rights risk to persons in care.

Official plan of correction

Licensee/Administrator will review Title 22 Sec. 87468.1 and agreed to review and understand the requirements in this section. Licensee will provide to LPA a written statement as proof that this section was review and will comply by POC due date: 11/18/22.

Deadline recorded: Nov 18, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(b)(1)(2)

Regulation authority

CCR

What the official deficiency says

87405 Administrator - Qualifications and Duties (b) The administrator of a facility.. shall have the responsibility and authority to carry out the policies... (1) Knowledge of the requirements for providing care and supervision... (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidenced by: Based on observation record reviews, and interviews, the Administrator failed to adhere to Title 22 regulations, resulting to multiple deficiencies cited. This violation poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee/Administrator will create a plan to ensure that the administrator performs knowledge of and conforms to applicable laws, rules and regulations. Plan of correction will be submitted by POC due date: 11/18/22.

Deadline recorded: Nov 18, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

80087(a)

Regulation authority

HSC

What the official deficiency says

80087(a)Buildings and Grounds(a)The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by: Based on interviews, and record review, the licensee failed to ensure that the facility was in good repair. On 6/2/22, at 10:30am, LPA and S1 observed Memory Care Dining Room ceiling missing plaster, partial open ceiling, and exposed mesh wire, which posed a potential health risk to residents in care.

Official plan of correction

Administrator will fax to LPA picture of repaired Memory Care Dining Rm ceiling, and also a signed self-certification statement that Administrator read and understands Regulation 80087 Building Grounds. POC Due Date is 6/10/22 LPA Fax Number (323)981-1781

Deadline recorded: Jun 10, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation), the licensee did not comply with the section cited above in [1] out of [13] [(rooms)[identify] did not provide hot water. This violation poses immediate health, safety, or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/19/2022 Plan of Correction Licensee will adhere to Title 22 Section 8703 (e) and ensure that water temperature is maintained to automatically regulate hot water not less than 105 degrees F and not more than 120 degrees F. The licensee will repair the water faucet in room 219 so that it will regulate hot water per regulations.

Official classification

Type A

Official code

87303(e)(1)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (1) All community care facilities where water for human consumption is from a private source shall: This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation), the licensee did not comply with the section cited above in [1] out of [13) [(rooms) room 219] did not provide hot water. This violation poses immediate health, safety, or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/19/2022 Plan of Correction Licensee will adhere to Title 22 Section 8703 (e)(1) and ensure that water temperature is maintained to automatically regulate hot water not less than 105 degrees F and not more than 120 degrees F. The licensee will repair the water faucet in room 219 so that it will regulate hot water per regulations.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) the licensee did not comply with the section cited above in [1] out of [13] [(rooms) failed to produce hot water for personal care use. The violation poses immediate health, safety, or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/19/2022 Plan of Correction Licensee will adhere to Title 22 Section 8703 (e)(2) and ensure that water temperature is maintained to automatically regulate hot water not less than 105 degrees F and not more than 120 degrees F. The licensee will repair the water faucet in room 219 so that it will regulate hot water per regulations.

Official classification

Type A

Official code

87465(g)

Regulation authority

CCR

What the official deficiency says

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 was not met as evidence by: Based on observation, interviews, and record reviews (R1) suffered head injuries during the fall. (R1) was not given immediate medical attention after a fall on 02/20/22. This violaiton poses an immediate health and safety risk to residents in care.

Official plan of correction

The licensee will submit a declaration on how staff will address injured residents shall be cared for in an emergency or resident care with primary care physician. LIcensee shall submit the protocol when dealing with emergency situaiton such as resident sustaining any injury by the POC date: 04/05/22. The emergency protocol shall state who is in charge of seeking medical care. Who to contact, who is in charge, and steps to be taken.

Deadline recorded: Apr 5, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional... appropriate assistance is provided when such observation reveals unmet needs... licensee shall ensure that such changes are documented and brought to the attention of the resident's physician... This requirement was not met as evidence by: Based on observation, interviews, and record reviews (R1) suffered head injuries during the fall. (S2-S5) observed physical changes in (R1) and failed to recognize to give immediate medical attention after a fall on 02/20/22. This violaiton poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee shall provide staff with training on observation of the residents. Licensee will provide copies of training materials and sign in sheet to CCL by POC 04/18/22 due date.

Deadline recorded: Apr 18, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(b)(2)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including:.(2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. This requirement was not met as evidence by: Based on LPA observations, interviews conducted and record reviews, the Licensee failed to ensure to address R1's history of wandering behavior and went missing, while unsupervised by facility staff. This violaiton poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee agrees that a Plan of Correction will be submitted to CCLD by 11/20/21. Administrator agreed that Arbor Hall staff will be advised to be on " high alert " meaning being more vigilant in monitoring all access exit door and windows while a Plan of Correction is developed by POC date 11/20/21 to the licening office.

Deadline recorded: Nov 20, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466 Observation of the Resident State regulations require the licensee to ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. Based on LPA observations, interviews conducted and record reviews, the Licensee was aware of of R1's history of wandering behavior failed to ensure proper supervision was in in place. This violation poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee shall have a written plan to ensure that in addition to the resident's needs and services plan a specific plan is drafted for each resident's change in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. The plan must be submitted by POC date 11/202/21 to the liceninsg office.

Deadline recorded: Nov 20, 2021. A deadline is not proof that correction was completed.