SAGE MOUNTAIN SENIOR LIVING

Official classification

Type B

Official code

87568.1(a)(8)

Regulation authority

CCR

What the official deficiency says

(8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. Based interviews and record review, the licensee did not comply with the section cited above when they did not inform R1’s responsible party of a fall with injury, which posed a potential health, safety and personal rights risk to residents in care.

Official plan of correction

Director of Health and Wellness agrees to update their electronic medical record system on who should be contacted first and will submit a plan of action on all of the details and when this will be done to LPA by 12/22/25

Deadline recorded: Dec 22, 2025. A deadline is not proof that correction was completed.

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 five out of ten restrooms that measured above the required 105-120 F temperature which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/20/2025 Plan of Correction ED agrees to adjust the hot water temperature today and submit proof (which can photos) of the new adjusted water temperature in rooms 109, 212, 217, 239, and 237 by 11/20/2025.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2(a)(4)residents…shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.This requirement is not met as evidence by: Based on staff interviews, the licensee did not comply with the section cited above when staff did not assist R1 to the restroom and paramedics were called to assist R1 which posed an immediate personal rights risk to residents in care.

Official plan of correction

Licensee will submit a plan how they will ensure residents receive the appropiate care.

Deadline recorded: Oct 31, 2025. 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

87468.2(a)(4)...residents…shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.This requirement is not met as evidence by: Based on self reported SOC341, the licensee did not comply with the section cited above, as resident was left with an infected wound for over 10 days before getting medical care which posed an immediate safety, and personal rights risk to residents in care.

Official plan of correction

S1 is no longer at the facility. Licensee agreed to submit a self-certification letter of understanding of regulation 87468.2 in its entirety and submit to LPA by 08/29/25.

Deadline recorded: Aug 28, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

A plan for incidental medical and dental care shall be developed by each facility. The plan shall...provide for assistance in obtaining such care...The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on Special Incident Report submitted Resident 1(R1) did not received medication ordered by physician on two seperate days which posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

S1 received medication training on 08/12/25. Administrator will submit proof of that training and Administrator agrees to submit a written statement of understanding of CCR 87465 in its entirety and plan on how they will ensure this wont happen again and will submit by 08/14/25.

Deadline recorded: Aug 14, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: This requirement was not met by evidence of eMAR indicating medication not provided in a timely manner. Which poses an immediate risk to Residents in care.

Official plan of correction

POC- Administrator agrees all MTs will receive Medication training that includes documentation, and medication distribution. Submit proof of training to CCLD by POC due date.

Deadline recorded: Jan 10, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet residents’ needs. This requirement is not met as evidenced by:Based on file review and interviews, the licensee did not comply with the section cited above as staff revealed that in 2023 the community was understaffed and were rushed to assist residents and residents had to wait long period of times to get assisted. This posed a potential health and safety risk for residents in care.

Official plan of correction

The ED agrees to submit a written plan that will be implemented when staff call out to ensure that there is always staff coverage at all times by 12/31/2024.

Deadline recorded: Dec 31, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2(a)(4)residents…shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.This requirement is not met as evidence by: Based on records review, the licensee did not comply with the section cited above as Staff did not respond to R1’s call for assistance in a timely manner, which posed a potential health and safety risk to residents in care.

Official plan of correction

ED agreed to have an in service with all staff regarding how to respond resident calls in a timely manner. Will submit proof of inservice to CCL by 12/10/23

Deadline recorded: Dec 10, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

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

Official plan of correction

POC Due Date: 11/19/2024 Plan of Correction Executive Dirctor removed all cleaning solutions from room #304 and #408 and will submit a letter of understanding of regulation 87309 by POC due date.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

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

Official plan of correction

POC Due Date: 11/19/2024 Plan of Correction ED removed all medications from all four rooms and greed to remove all medications from all four rooms and submit a plan on how they will ensure the safety of their residents and that medication will be locked and inaccessible to residents in care. Submit plan by the end of the day on POC.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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 in three of ten rooms observed as the floors of rooms 249, 233 and 238 were not sanitary which posed a potential health and safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/18/2024 Plan of Correction Plan of correction has been met, rooms were cleaned during todays visit.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

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

Official plan of correction

Staff secured the cleaning items during the visit. Executive Director agrees to provide training to the staff that left the cart unattended regarding the regulation and submit proof by plan of correction date 10/08/2024.

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

Official classification

Type A

Official code

87625(b)(3)

Regulation authority

CCR

What the official deficiency says

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

Official plan of correction

The ED shall submit a written memo of understanding of 87625 and also a plan indicating how the care staff will ensure that all incontinent residents are receiving proper and timely care in accordance with the regulation. Submit by 06/26/2024. ED will aslo ensure care staff receives training on the plan and submit in-service sign in sheets.

Deadline recorded: Jun 26, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87507(f)

Regulation authority

CCR

What the official deficiency says

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

Official plan of correction

The ED agreed to write a self-certification letter that they will follow up with coorperate, and Milestone management company in regards to R1's credit/refund, and issue a refund if needed. Will also wite a plan on how they will ensure refunds/credits are handled appropiately. Submit POC by 07/05/2024.

Deadline recorded: Jun 5, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

00000

Regulation authority

CCR

What the official deficiency says

This is an amended report. This page intentionally left blank

Deadline recorded: Jun 21, 2024. 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

87468.2(a)(4)residents…shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above when staff did not respond to R1’s call for assistance and did not seek timely medical treatment for R1 on two occasions, which posed an immediate health and safety risk to residents in care.

Official plan of correction

Licensee will submit a plan how you will ensure residents receive assistance in a timely manner. Submit to CCL by 06/19/2024

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

Official classification

Type A

Official code

87465(j)

Regulation authority

CCR

What the official deficiency says

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

Official plan of correction

Licensee will submit a plan how you will ensure residents receive timely medical assistance. Submit to CCL by 06/19/2024.

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

Official classification

Type B

Official code

87217(b)

Regulation authority

CCR

What the official deficiency says

87217(b) Safeguards for Resident Cash, Personal Property, and Valuables Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. Based on interviews S2 admiited to taking R1's incontinence supplies which posed a potential health and safety risk to residents in care.

Official plan of correction

Administrator will submit a plan to properly safeguard residents' property as well as provide staff training regarding safeguarding residents' personal property. Submit to CCL by 06/28/2024.

Deadline recorded: Jun 28, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(c)(1)

Regulation authority

CCR

What the official deficiency says

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

Official plan of correction

Administrator agreed to submit a statement of understanding of regulation 87506 and will make a plan on how to follow up on record requests in a timely manner and notify resident or resident's authorized person if they do not have the records, will submit to CCL by 6/28/24. Administrator will also follow up on the record request for R1.

Deadline recorded: Jun 28, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.153(c)(d)

Regulation authority

CCR

What the official deficiency says

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

Official plan of correction

POC: The Executive Director has agreed to the following: The ED has agreed to the following: 1. Have an in-service training with staff regarding the facility’s theft and loss policy. Submit training documentation to CCL by POC date.

Deadline recorded: May 31, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

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

Official plan of correction

POC: Executive Director agrees to re-evaluate care response system that is conducive to residents’ needs.

Deadline recorded: May 31, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(2)

Regulation authority

CCR

What the official deficiency says

87468.2 (a) In addition to the rights listed in Section 87468.1,....(4)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above as staff failed to respond timely to an emergent situation pertaining to R1 which posed an immediate health and safety concern to R1 in care.

Official plan of correction

Licensee will submit a plan how you will ensure appropriate resident care and supervision, including medical intervention during an emergency. Submit to CCL by 2/2/2024.

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

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements (c)All RCFE staff who assist residents... (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.This requirement is not met as evidenced by Based on record review, the licensee failed to comply with the section cited above as S2’s first aid certification expired in February 2022, and S2 did not have a current certificate during the incident on 01/24/2023 which posed a health and safety risk to residents in care.

Official plan of correction

Licensee will submit a plan how you will ensure all staff have current first aid training. Submit to CCL by 1/09.2024

Deadline recorded: Feb 9, 2024. 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

87468.2(a)In addition to the rights listed in Section 87468.1 (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.This requirement is not met as evidenced by: Based on interviews & records review, the licensee did not comply with the section cited when there was not sufficient, competent staff to provide timely first aid assistance to R1, resulting in death by choking, which posed an immediate health and safety risks to

Official plan of correction

Licensee will submit a plan how you will ensure appropriate resident care and supervision, including medical intervention during an emergency. Submit to CCL by due date of 2/02/2024. residents in care.

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

Official classification

Type A

Official code

1569.695(a)(2)

Regulation authority

HSC

What the official deficiency says

(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as the faciltiy did not have a supply of emergency food and water which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 11/24/2023 Plan of Correction The Licensee agreed to do the following: 1. Obtain a supply of emergency food and water and store away from day to day food and water supplies. Provide proof to CCL no later than the POC date.

Official classification

Type B

Official code

87303(a)(1)

Regulation authority

CCR

What the official deficiency says

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. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above as in bedroom 319 did not have a comfortable temperature for the resident, based observation room #241 had a strong odor emitting from the bathroom and carpet next the closet which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 11/24/2023 Plan of Correction The Licensee agreed to the following: 1. Adjust temerpature and maintan consisent comfortable temeprature for resident in room 319. Record temps for 5 days and provide proof to CCL no later than POC date. 2. Clean carpet and bathroom and provide proof to CCL.

Official classification

Type B

Official code

87303(e)(6)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as sink in bedroom #241 was not draining and retaining the water which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 11/24/2023 Plan of Correction Licensee agreed to the following: 1. Repair sink to ensure proper drainage and provide proof to CCL no later than POC due date.

Official classification

Type B

Official code

1569.625(b)(1)(2)

Regulation authority

HSC

What the official deficiency says

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

Official plan of correction

The Business Office Manager and Administrator agrees to submit proof S1, S3, and S4 have proof of all required training to CCL by 08/22/2023.

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

Official classification

Type B

Official code

1569.69

Regulation authority

HSC

What the official deficiency says

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

Official plan of correction

The Business Office Manager agrees to submit proof S1, S2, and S3, have current annual medication training to CCL by 08/22/2023.

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

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (c)(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Based on record review, the licensee failed to comply with the section cited above as six out of six files reviewed did not have proof of first aid training which poses a potential health and safety risk to residents in care.

Official plan of correction

The Business Office Manager agrees to submit proof S1, S2, S3, S4, S5, and S6 have proof of current first aid training by 08/22/2023.

Deadline recorded: Aug 22, 2023. 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

87468.2 (a) In addition to the rights listed in Section 87468.1,....(4)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on record review and interview, the licensee failed to comply with the section cited above as R1 is a two person assist and only received assistance from one staff member while transferring in the shower resulting in injury which is health and safety risk to R1 in care.

Official plan of correction

The Administrator agrees to have an in-service training regarding R1's care plan and specifically the need for a two person assist and submit proof to CCL by 07/26/2023.

Deadline recorded: Jul 26, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (c)(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidence by: Based on record review, the licensee failed to comply with the section cited above as one resident with dementia had a medical assessment older than one year which poses a potential health and safety risk to residents in care.

Official plan of correction

The Director of Nursing agrees to get an updated medical assessment for R1 and submit to CCL by 07/14/2023.

Deadline recorded: Jul 14, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(4)To care, supervision, and services that meet their..needs and are delivered by staff that are sufficient in numbers, qualifications, and competency... This requirement is not met as evidenced by: Based on interviews and record review, the licensee failed to comply with the section cited above as three residents (R2, R4, R6) had pendent call wait times in excess of 20 minutes which poses an immediate health and safety risk to residents in care.

Official plan of correction

The Administrator shall submit a plan by 06/07/2023 indicating how they will ensure timely pendent response times for all residents in the community.

Deadline recorded: May 24, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

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

Official plan of correction

The Administrator shall submit proof of an in-service training with current medication techs to ensure the deficiency does not occur again. Proof of training shall be submitted by 06/07/2023.

Deadline recorded: Jun 7, 2023. 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

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(4)To care, supervision, and services that meet their..needs and are delivered by staff that are sufficient in numbers, qualifications, and competency... This requirement is not met as evidenced by: Based on interviews and record review, the licensee failed to comply with the section cited above as three residents (R2, R4, R6) had pendent call wait times in excess of 20 minutes which poses an immediate health and safety risk to residents in care.

Official plan of correction

The Administrator shall submit a plan by 06/07/2023 indicating how they will ensure timely pendent response times for all residents in the community.

Deadline recorded: Jun 7, 2023. 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

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(4)To care, supervision, and services that meet their..needs and are delivered by staff that are sufficient in numbers, qualifications, and competency... This requirement is not met as evidenced by: Based on interview and record review, the licensee failed to comply with the section cited above as R1 had approximately 46 pendent response time in excess of 20 minutes during a one month time period which is an immediate personal rights and health and safety risk to R1 in care.

Official plan of correction

The Administrator shall submit a plan by 04/20/2023 indicating how they will ensure timely pendent response times for R1 and all residents in the community.

Deadline recorded: Apr 20, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1

Regulation authority

CCR

What the official deficiency says

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

Official plan of correction

The Administrator shall submit a plan of correction by 02/17/2023, indicating how they will prevent this violation from occurring again.

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

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

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

Official plan of correction

This is a repeat violation of a citation issued on 03/22/2022. Subsequent violations within a twelve (12) month period will result in a civil penalty of one hundred ($100) per violation per day for a maximum of thirty (30) days. See LIC 421BG. Plan of correction is cleared as S1 was associated to the facility during today's inspection.

Deadline recorded: Jan 18, 2023. 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....that appropriate assistance is provided when such observation reveals unmet needs... This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above section, as Resident #1 (R1) had a change of contition, and the facility did not intervene nor report, which poses an immediate health and safety risk to residents in care.

Official plan of correction

Executive Director has already trained all staff on the change of condition criteria and have been following newer protocols regarding resident observation and care notes. Training has been conducted and documented. POC cleared.

Deadline recorded: Oct 26, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87463(b)

Regulation authority

CCR

What the official deficiency says

87463 Reappraisals (b) The licensee shall immediately bring any such changes to the attention of the resident's physician and his family or responsible person. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above section, as R1 had significant weight loss, decreased oral intake, and increased falls and no reappraisal was completed, which poses an immediate health and safety risk to residents in care.

Official plan of correction

Executive Director has changed the assessment criteria. Staff have been trained and are doing reassessments on residents who have a need monthly. Families are notified and sign the reassessments. POC cleared.

Deadline recorded: Oct 26, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on interview, observation, and record review the licensee did not comply with the above cited section, as facility staff were aware R1 was a fall risk, R1 fell multiple times, and the falls weren't reported, which posed an immediate health and safety risk to residents in care.

Official plan of correction

Executive Director is conducting training monthly on basic services and meeting the residents needs. LPA observed inservice documentation during today's visit. POC cleared.

Deadline recorded: Oct 26, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

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

Official plan of correction

Executive Director and Health & Wellness Director have modified the facility's medication plans, medication audits are conducted quarterly and residents' physicians are communicated with regularly & documented as thus. POC cleared.

Deadline recorded: Oct 26, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87555(b)(5)

Regulation authority

CCR

What the official deficiency says

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

Official plan of correction

Executive Director has modified the initial assessment process and the 30 day post-move in assessment to ensure resident needs were met. Physician's reports are reviewed with the Kitchen staff and Dietician. Additional vegan protein options are now available. POC cleared.

Deadline recorded: Oct 26, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

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

Official plan of correction

The Administrator shall submit proof staff who are responsible for submitting written incident reports to CCL have had training in regards to regulation 87211. Proof shall be submitted to CCL by 10/21/2022.

Deadline recorded: Oct 21, 2022. 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

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidence by: Based on observation, the licensee failed to comply with the section cited above, as the delayed egress auditory alarm located in the memory care front desk/medication room was not operational which poses a potential health and safety risk to residents in care.

Official plan of correction

The business manager and maintenance director agreed to have an in-service today to advise staff that the auditory alarm is not operational. Proof all staff have been notified shall be submitted to CCL by 10/18/2022.

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

Official classification

Type A

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

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

Official plan of correction

The Administrator shall submit a plan with procedures on how they will protect the safety, acceptability and nutritive values of food served. The plan shall be submitted by 08/05/2022. (Items in question were disposed of during the inspection.)

Deadline recorded: Aug 5, 2022. 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

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

Official plan of correction

An elopement drill was conducted with staff and S1 will no longer work at the facility. Plan of correction is cleared.

Deadline recorded: Jun 10, 2022. 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

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on observation and interview, the licensee failed to comply with the section cited above as a phone number was not posted on the locked entry door for after hour guests, emergencies, deliveries, etc. to alert staff of their presence which poses a potential health, safety, and personal rights risk to residents in care.

Official plan of correction

A sign with the medication room phone number was posted on the front door during the inspection. Plan of correction is cleared.

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

Official classification

Type A

Official code

1569.312(a)

Regulation authority

HSC

What the official deficiency says

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

Official plan of correction

LIcensee will submit a plan to provide proper level of care and supervision to ensure residents' needs are met. Plan must be submitted to CCL on or before 04/06/2022.

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

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

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

Official plan of correction

This is a repeat violation of a citation issued on 11/22/2021. Subsequent violations within a twelve (12) month period will result in a civil penalty of one hundred ($100) per violation per day for a maximum of thirty (30) days. Civil penalties of $100 a day will continue to accrue until proof S1 & S2 are associated or proof they no longer work at the facility.

Deadline recorded: Mar 22, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

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

Official plan of correction

The Administrator shall submit proof by 03/04/2022 that all staff have received training regarding the facility policy of all staff having an iPod on them during their work shift and also ensuring the Ipods are always charged and staff have access to their iPod log on and delayed egress training. By 03/11/2022, the Administrator shall submit proof a modification has been made so that the alarm is audibly heard inside the memory care.

Deadline recorded: Mar 11, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(2)

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

Official plan of correction

POC Due Date: 11/22/2021 Plan of Correction The licensee shall submit the request of transfer of criminal record clearance for Staff #1 (S1). A civil penalty is being assessed and will continue to accrue until the transfer request is submitted.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

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

Official plan of correction

POC Due Date: 12/03/2021 Plan of Correction The door was locked during the inspection. The administrator shall submit proof that staff who work in the memory care had an in-service training regarding regulation 87705 and submit proof to CCL by 12/03/2021.

Official classification

Type B

Official code

1569.695(a)(2)

Regulation authority

HSC

What the official deficiency says

(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above as the facility had no bottled water or any other emergency water which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/26/2021 Plan of Correction The Director of Culinary stated they will have 25 five gallon jugs of water by Wednesday and a case of water for each resident room. Proof shall be submitted by 11/26/2021 that the facility has enough water for all residents and staff to be no self-reliant for no less than 72 hours.