ESKATON GOLD RIVER LODGE

Official classification

Type B

Official code

87468.1(a)(1)

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: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidence by: Based on interviews and record review, Licensee did not ensure a dignified relation between a staff member and resident in care regarding care procedures. This posed a potential health, safety, and resident rights risk to residents in care.

Official plan of correction

Licensee will ensure completed staff training on resident rights. Training to include but not be limited to Section 87468.1(a)(3). Proof of completed training to be submitted to LPA by POC due date.

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

Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional... appropriate assistance is provided... The Licensee did not meet the above requirement when: Based on a review of records and interviews, staff became aware of R1 having a change in condition on 11/5/2024 and staff did not contact R1’s (PCP) when the change of condition was noted. This posed an immediate threat to the health, safety and personal rights of residents in care.

Official plan of correction

The Licensee hired a new Executive Director as of 12/05/24 and the new ED has held the team accountable with regard to reporting requirements and residents' change of condition. There is also a new Resident Care Director to oversee assessments, re-appraisals and family care conferences This POC has been cleared.

Deadline recorded: Aug 21, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)

Regulation authority

CCR

What the official deficiency says

Additional Personal Rights of Residents in Privately Operated Facilities (20) To be protected from involuntary transfers, discharges, and evictions... The Licensee did not meet the above requirement when: Based on a review of records and interviews, on 11/19/24, the RCC did not allow R1 to return to the facility when the hospital tried to discharge R1 so R1 could return home. This posed an immediate risk to the health, safety, and personal rights of residents in care.

Official plan of correction

The ED will communicate with residents and responsible parties Eskaton's policy regarding resident transfers and the use of mechanical lists. This will be accomplished though a recorded Family Meeting on 08/21/25. The agenda and link to the meeting will be forwarded to CCLASCPSacramentoRO@dss.ca.gov.

Deadline recorded: Aug 21, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by:Administrator, LPA and Regional manager observed medication unlocked in two residents rooms that administer their own medications. Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in 2 of 4 rooms inspected which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/18/2025 Plan of Correction The facility will reassess R1 and R2 for self administration of their medication including keeping medication locked and not accessible to others.

Official classification

Type B

Official code

87470(b)(2)

Regulation authority

CCR

What the official deficiency says

Infection Control Rqmts. 87470(b)(2) (b) In addition to ...with a contagious...(2) All staff ...Personal Protective Equipment (PPE) to prevent exposure to infectious agents... The licensee did not ensure the above regulation was enforced as evidenced by: Based on interviews with S2 and S3 along with this LPA's observations on 11/14/25, 3 staff members were not following the infection control protocol and were not wearing masks/PPE. This posed a potential threat to the health, safety, and/or personal rights of residents in care.

Official plan of correction

The ED stated that since the time of this complaint, addtional trainings on infection control procedures have taken place and staff who did not/do no follow those protocols have been/will be counseled and disciplined. ED will provide LPA with documentation showing the trainings and disciplianry actions that were conduted. This infomation will be submitted to CCL and a copy to the LPA at CCLASCPSacramentoRO@dss.ca.gov by close of business 6/06/25.

Deadline recorded: Jun 6, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87405(b)

Regulation authority

CCR

What the official deficiency says

Administrator Qualifications (b) The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee. This requirement was not met as evidenced by: Based on interviews and records review, the Administrator did not ensure that the COVID-19 Preparedness and Response Plan was implemented. Residents were not tested upon move-in, additional testing was not conducted immediately on those who were in proximity of infected residents, and staff did not wear masks in communal areas. This posed an immediate risk to the heath, safety, and personal rights of residents in care.

Official plan of correction

Administrator will develop and submit a plan for conducting an inservice on idenitifying COVID symptoms in addtion to reviewing the COVID Preparedness and Response Plan. The plan for this inservice and an outline of what it will cover will be submitted to kimberly.viarella@dss.ca.gov by 9/18/24 and the trainings (for all care staff and leadership) will be completed by 10/11/24. Signature sheets will be submitted to CCL at the the aove email address.

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

Official classification

Type A

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental (a) ... incidental medical and dental care shall be developed by each facility... provide for assistance in obtaining such care ...(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Based on interviews and a review of records, R1 was denied medical assistance when they requested a COVID test. This posed an immediate risk to the health, safety and personal rights of residents in care.

Official plan of correction

Administrator will arrange for an inservice for med techs on personal rights, the date of which will be submitted to CCL at the email above by 9/18/24. The training will be completed by 10/11/24 and signatures sheets will be submitted to CCL at the email above.

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

Official classification

Type B

Official code

97555(b)(9)

Regulation authority

CCR

What the official deficiency says

General Food Service-The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This was not met as evidenced by: Based on interviews, food was not being served at the appropriate temperature due to equipment malfunction, the placement of a fan over the hood in the kitchen, and staff not being trained to pace meals. This posed a potential threat to the health, safety and/or personal rights to residents in care.

Official plan of correction

The facility has repaired or replaced the faulty equipment, trained kitchen staff not to place food under the hood until it is time to be delivered, and trained server to pace meals. This plan of correction has already been met. This POC has been cleared.

Deadline recorded: Jul 17, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(d)(3)

Regulation authority

CCR

What the official deficiency says

(d) All personnel shall be given on the job training... provide knowledge of and skill in the following...as evidenced by safe and effective job performance: (3) ... to provide necessary resident care and supervision... The facility did not meet the above requirement as evidenced by: 2 out of 9 staff interviewed stated that employees were using the Hoyer lift by themselves and not requesting a second person to assist.

Official plan of correction

Designated Facility Administrator stated they will do additional training on Hoyer operation for Memory Care staff. The nursing staff will develop and conduct the training by 07/23/23. An outline of the training along with signature sheets will be submitted to CCL at kimberly.viarella@dss.ca.gov.

Deadline recorded: Aug 23, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

(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: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above when the LPA observed a sharp 6 inch serrated knife in a memory care kitchenette cabinet and when she observed scissors in kitchenette drawer. These items posed/poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/12/2024 Plan of Correction Designated Facility Administrator immediately removed prohibited items and has stated they will do daily checks of the common areas in memory care which will be logged. This log template will be submitted by 6/13/24 close of business and the logs themselves will be submitted to kimberly.viarella@dss.ca.gov by 6/20/24.

Official classification

Type B

Official code

1569.625(b)(1)

Regulation authority

HSC

What the official deficiency says

(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review and an interview with the Facility Administrator, the licensee did not comply with the section cited above as observed by they LPA during a review of staff files. In 2 of the 3 staff files, there was no proof of initial training documented. This posed a potential threat to the health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/11/2024 Plan of Correction Designated Facility Administrator stated that he will provide an audit of all missing training for care staff and med techs and will also update Eskaton Academy materials to provide regulation references. This information will be submitted to kimberly.viarella@dss.ca.gov by 7/11/24.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Deficient Practice Statement Based on a records a review and an interview with the Designated Facility Administrator, the licensee did not comply with the section cited above when 2 out of 3 staff files were missing required annual training components. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/30/2024 Plan of Correction Designated Facility Administrator stated that he will provide an audit of all missing training for care staff and med techs and will also update Eskaton Academy materials to provide regulation references. This information will be submitted to kimberly.viarella@dss.ca.gov by 7/11/24.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

(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: Deficient Practice Statement Based on a records review and interview with the Designated Facility Administrator, the licensee did not comply with the section cited above when 2 out of 3 staff files reviewed staff did not have a current first aid/CPR certification. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/11/2024 Plan of Correction The Designated Facility Administrator stated he will have all care staff /medtechs First Aid/CPR certified by 07/11/24. Copies of certifications will be submitted to kimberly.viarella@dss.ca.gov.

Official classification

Type A

Official code

873559(e)

Regulation authority

CCR

What the official deficiency says

e) 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: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review and interview with the Designated Facility Administrator, the licensee did not comply with the section cited above when a minor hired to work as a server turned 18 last summer and the licensee did not obtain a background check clearance for them. This posed / poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/12/2024 Plan of Correction Facility sent the staff member to be fingerprinted and they will not return to work until they have been cleared. THis POC has been cleared. As follow up, proof of clearance will be sent to kimberly.viarella@dss.ca.gov.

Official classification

Type A

Official code

87355(e)(3)

Regulation authority

CCR

What the official deficiency says

(e) 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: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c)... This requirement is not met as evidenced by: Deficient Practice Statement Based on a record review and an interview with the Business Office Manager, the licensee did not comply with the section cited above when 4 employees transfered to this facility but requests for them to be associated were not completed. This posed / poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/12/2024 Plan of Correction These transfer requests have been completed. This POC has been cleared.

Official classification

Type A

Official code

87355(e)(3)

Regulation authority

CCR

What the official deficiency says

(e) 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: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: Plan of Correction

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

Basic Services: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by resident (R1) was witnessed on video leaving the facility at 7:30pm, the facility doors were locked while the resident was still outside walking their dog. As a result, the resident was not noticed as missing and was not discovered by staff until the following morning. The coroner’s determination of death for the resident is hypothermia. Per the facility plan of operation, supervision would include health checks for all residents at a minimum of every two hours. R1 and the facility had a no check agreement from 10pm until 6am. Per the facility’s plan of operation, R1 should have been checked on between the time they exited the facility until R1’s agreed upon no check time that exceed two hours and was not consistent with the facility’s own plan of operation which poses an immediate health safety and personal rights risk to residents in care.

Official plan of correction

facility will establish a documentation of resident whereabouts and confirm their presence at the facility at the beginning and end of each shift. facility will submit a written plan establishing the supervision of residents.

Deadline recorded: Feb 8, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

Personnel Requirements – General: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement was not met as evidenced by staff actions when encountering a known resident’s dog unattended, no staff member checked on resident for over 20 minutes prior to being discovered in the front of the building and did not display competency in their job performance by not checking on resident who was in a stated of distress which poses an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

Facility had agreed to conduct emergency response training with staff and document the proceedures in place all staff members must follow including steps and actions each staff member is required to make when a resident is experiencing a medical emergency. Procedures and trinaing material will be provided by the POC due date.

Deadline recorded: Nov 17, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87466

Regulation authority

CCR

What the official deficiency says

Observation of 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. When changes such as unusual weight gains or losses or 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 and the resident's responsible person, if any. This requirement was not met as evidenced by statements by facility and outside care providers and documentation of concerns of Resident cognitive decline prior to the last resident care meeting with authorized provider and the resident’s death which poses a potential health, safety, and personal rights risk for residents in care.

Official plan of correction

LPA and facility discussed the development of a " red flag " system where by a resident with an observed change in condition is red flagged by a staff member onthe community board and thus alerting all staff members. the red flag notice will remain on the resident's board untill re-evluated by a physician or teh care plan is changed to reflect additional resident needs for care and supervision.

Deadline recorded: Nov 30, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(d)

Regulation authority

CCR

What the official deficiency says

Basic Services: A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-Admission Appraisal and providing the other basic services specified below, either directly or through outside resources. This requirement was not met as evidenced by a care meeting taking place with resident, their authorized representatives and facility staff where resident’s increased medical needs and physical decline was discussed. Despite the admission of a change of condition and increased medical needs, no changes to the resident’s care plan or increased supervision were established which poses an immediate health, safety, or personal rights risk to residents in care.

Official plan of correction

Facility will provide a written plan of correction by the POC date to incorporate a " red flag " system by where a resident with a change in condition is red flagged and is automatically placed on frequent checks until the resident is reasessed or a new care plan is put in place and the red flag is removed.

Deadline recorded: Nov 17, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(b)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements: Any suspected physical abuse that results in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within two (2) hours as required by Welfare and Institutions Code Section 15630(b)(1) Which poses a potential Health, safety and personal rights risk to residents in care.

Official plan of correction

Facility has agreed to conduct additional training on reporting requirements and provide evidence of topics discussed during the training and documentation training was received by all mandated reporters at the facility.

Deadline recorded: Nov 30, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by LPA's interviews with staff and self reported incident report that details how resident was given and incorrect dose of acetaminophen on 6/25/23 when the medication was provided two hours before the next scheduled dose, which poses an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

Facility has conducted retaining of the staff member including staff shaddowing and are in process of reevaluating annual ongoing training for medication staff.

Deadline recorded: Jul 13, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by LPA's interviews with staff and self reported incident report that details how resident was given and incorrect dose of insulin on 6/9/23 when no insulin should have been provided to the resident which poses an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

LPA and Administrator together developed a POC: The facility will provide a written plan of correction regrading changes to the administration of insulin: including but not limited to the development of a mobile insulin MAR where documentation of the recorded blood glucose is documented and recorded prior to drawing insulin or assisting residents with self administration of insulin.

Deadline recorded: Jun 22, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by LPA's interviews with staff and self reported incident report that details how resident was given and incorrect doses of insulin on 4/16 and 4/26 which poses an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

Facility will conduct medication administration retaining for both staff members responsible for medication errors and will provide the department with a written explanation of the new medication administration process for insulin for all residents.

Deadline recorded: May 5, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87463(c)

Regulation authority

CCR

What the official deficiency says

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by: Deficient Practice Statement Based on the review of 11 resident files, the licensee did not comply with the section cited above in 1 out of 11 resident files reviewed where the LIC 602 physician's report was not updated annualy per regualtions which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/05/2023 Plan of Correction facility will provide a written plan of correction providing the specific practices that will be incorportated into the facility operation to ensure all residents with a diagnosis of dementia are reassessed every 12 months.

Official classification

Type A

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

Incidental Medical and Dental Care: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by LPA's interviews with staff and self reported incident report that details how resident was given and additional dose of weekly medication which poses an immeated health, safety and personal rights risk to residents in care.

Official plan of correction

Facility will provide the department with documentation of retaining for staff member who administered incorrect medication.

Deadline recorded: Jan 5, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by LPA's interviews with staff and self reported incident report that details how resident was given and additional dose of weekly medication which poses an immeated health, safety and personal rights risk to residents in care.

Official plan of correction

Facility will conduct retraining for staff identified as responsible for the medication error and provide documentation of medication administration training to the department by the POC due date.

Deadline recorded: Oct 24, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87463(a)(2)

Regulation authority

CCR

What the official deficiency says

Reappraisals: 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. Significant changes shall include but not be limited to: A mental/social trauma such as the loss of a loved one. This requirement was not met as evidenced by facility staff did not arrange for R1 to be reappraised after being informed of R1’s statements of suicidal ideation on 5/14/22 which poses an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

The facility has agreed To provide training for staff to ensure staff member report instances of residents threatening self harm. Facility will also develop additional screening and reappraisals for any resident struggling with mental health or any change in condition.

Deadline recorded: Sep 6, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

Additional Personal Rights of Residents in Privately Operated Facilities: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by facility did not provide enhanced safety checks for resident who expressed suicidal ideation on 5/14/22 resulting in resident committing suicide on 5/30/22 which poses an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

the facility has agreed to provide detailed steps facility will take including companionship and supervision including linkages with family/friend support in conjunction with the a resident's primary care physician and referral to a psychiatric services in the event of a resident expressing suicidal ideation.

Deadline recorded: Sep 6, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(g)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care: 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 except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement was not met as evidenced by when staff discovered R1 the staff did not immediately contact 911 for emergency services and instead sought additional support from additional facility staff which may have delayed first responders from initiating timely aid to the resident which poses an immediate health, safety and personal right risk to residents in care.

Official plan of correction

The facility has agreed to provide training for all facility staff on emergency procedures and provide LPA with a copy of training materials and documentation that all staff received training.

Deadline recorded: Sep 6, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

HSC

What the official deficiency says

Personnel Requirements: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement was not met as evidenced by LPAs observation of camera recordings of the incident between R1 and R2 in a common area of the memory care unit where no staff were present to intervene and meet the needs of the resident which poses an immediate health and safety risk to residents in care.

Official plan of correction

Facility will provide the department with a written plan for routine surveillance and ensuring as staff presence and monitoring of residents to prevent further instances from reoccurring at the facility.

Deadline recorded: Feb 25, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

Personal Rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by multiple acts of aggression by R2 against R1 documented by the facility which poses a potential health and safety risk to residents in care.

Official plan of correction

Facility will provide the department with a written plan to address the steps facility will take to ensure resident safety when a resident displays an act of aggression towards another resident.

Deadline recorded: Mar 4, 2022. A deadline is not proof that correction was completed.