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32 | LPA review of the facility call system records for resident calls from 4/1/2025 to 5/1/2025 revealed 130 pendant calls and 10 resident bathroom pull cord alerts with response times over 10 minutes; of which 16 were over 20 minutes, 12 were over 30 minutes, and 6 were over 60 minutes. LPA staff interviews revealed there are times that residents have to wait for extended periods of time to receive assistance since staff are helping other residents. Staff also stated in interviews that the call system does not always function properly, sometimes losing Wi-Fi signal and other times they forget to follow through timely completing all the steps of restoring resident pendant and bathroom devices. LPA resident interviews revealed 6 of 7 interviewed residents state they do sometimes wait for extended periods of time for staff to respond. Based on all interviews conducted and record review, at this time the above allegation was found to be substantiated, there is a preponderance of the evidence to prove that the alleged violation occurred.
On allegation: Residents are not being provided clean linens. It was alleged that staff are covering the dirty areas of the linens and not providing residents with clean linens. LPA interviews with staff revealed that care staff in the memory care unit are responsible for changing linens 2-3 days each week and more often when soiled. Staff interviews in the assisted living unit revealed housekeepers are responsible for changing sheets once per week and care staff are responsible for changing the linens when soiled. During multiple visits to the facility from 3/17/2025 and 7/8/2025 LPA observed and photographed 7 resident rooms with soiled and stained linens. Additionally LPA noted 6 rooms with stained and soiled mattresses and/or mattress covers. Based on LPA observation, at this time the above allegation was found to be substantiated, there is a preponderance of the evidence to prove that the alleged violation occurred.
On allegation: Staff does not keep facility free from odor. It was alleged a resident in memory care, Resident #3 (R3), urinates on the floor of their room, the room smells of urine and staff do not always clean it up. On 5/7/2025 LPA and Administrator toured the facility including R3’s room. LPA noted a very strong smell of urine. Upon inspection of the room at 11:54am LPA and Administrator noted in the south/east corner of the room the laminate floor boards, baseboard, and paint on the walls peeling away from the floor and walls. Administrator stated this is due to the resident urinating in various areas of their room including that corner and there was a plan to repair the flooring, baseboard, and paint.
(Continued on LIC9099-C)
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32 | LPA interviews with staff revealed 5 of 5 staff are not aware of R1 being left in soiled clothing. Staff interviews and record review revealed R1 is incontinent, R1 often refuses staff assistance and staff make multiple attempts to assist R1 when they refuse. During LPA interview with R1, R1 stated staff check on them too frequently and staff do provide assistance with their dressing and incontinence needs. R1 stated they have not been left in soiled clothing by staff. Based on all interviews conducted, LPA observation and record review, at this time the above allegation was found to be unsubstantiated, meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.
On allegation: Call button not accessible to residents. It was alleged that not all residents in the memory care unit have call buttons accessible to them. LPA interview with the Administrator reveal there is an emergency pull cord in every resident bathroom and it is Westmont Living's policy to check the residents more frequently in memory care since as they may not be able to operate a pendant. Administrator also stated if a resident requests a pendant the facility provides that resident one. LPA interview with staff revealed that currently two memory care residents carry a pendant with them and the other residents who do not are checked on more frequently. LPA observed each resident bathroom has an emergency pull cord meeting regulation requirements. Based on all interviews conducted and LPA observation, at this time the above allegation was found to be unsubstantiated, meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.
On allegation: Staff do not meet residents’ needs. It was alleged Resident #2 (R2) has fallen multiple times, pushes their pendant for assistance, and it takes a while for staff to respond. LPA call system record review from 4/1/2025 to 5/1/2025 revealed 24 pendant calls from R2 with a response time over 10 mins. LPA record review of R2’s LIC602 Physician Report dated 3/28/2025 revealed R2’s secondary diagnoses to be falls and gait instability and on page 2 of the LIC602 motor impairment is marked “yes” with the physician comment “unsteady gait”. LPA noted R2’s Service Plan dated 4/29/2025 states R2 needs caregiver standby assistance with mobility using a walker or wheelchair daily, and a comment stating, “the Care Team supports me with safe ambulation, mobility and repositioning.”
(Continued on LIC9099-C)
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
08/06/2025
Section Cited
CCR
87468.2(a)(4) | 1
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7 | (a)... residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (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.
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7 | Administrator stated they will move a screen that displays resident calls at the concierge station on 7/24/2025 more in view of the concierge to provide staff reminders, two weeks ago new staff devices were purchased to receive emergency resident alerts, and will train staff and provide LPA via email training and signed roster on or before 8/6/2025. |
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14 | This requirement was not met as evidenced by:
Based on interviews and record review, the licensee did not comply with the section cited above when 6 of 7 residents stated they wait for staff to respond, 130 call response times were | 8
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14 | over 10 minutes, and when staff stated the system does not always work which poses a potential health, safety, and personal rights risk to clients in care. |
Type B
08/06/2025
Section Cited
CCR
87303(a) | 1
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7 | 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 was not met as evidenced by: | 1
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7 | Administrator states the facility has hired additional housekeeping staff, they will schedule housekeeping in memory care daily, create a quality control check to ensure residents are provided clean linens, and schedule R3's room to be repaired. Administrator will email |
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14 | Based on interviews and record review, the licensee did not comply with the section cited above when 7 rooms had stained/soiled linens, and when LPA noted R3's room with an odor and in disrepair which poses a potential health, safety, and personal rights risk to clients in care. | 8
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14 | housekeeping schedule, quality control check docmuent and date(s) of scheduled repair to LPA on or before 8/6/2025. |