Inspection Reports for Mercy McMahon Terrace

The inspection was an unannounced annual inspection conducted by Licensing Program Analysts Kevin Gould and Holly Williams to evaluate compliance with regulations at Mercy McMahon Terrace facility.

The inspection found that the facility generally met environmental and safety standards, including adequate furnishings, proper temperature controls, and secured storage for medications and hazardous materials. However, a deficiency was cited for an unlocked medication cart accessible to a resident who was not allowed to self-administer medications, posing an immediate health and safety risk.

The visit was an unannounced case management inspection conducted to investigate allegations of staff mishandling a resident.

The investigation found that staff member S13 aggressively wiped a resident's face and neck and failed to change the resident's soiled diaper for at least two hours despite reminders from other staff. The facility terminated S13 based on multiple witness accounts.

The complaint was substantiated based on interviews with three staff members and the victim resident confirming the allegations against staff member S13.

The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2024-08-26 regarding unsafe accommodations and insufficient staffing at the facility.

The investigation found insufficient evidence to substantiate the allegations. The facility was observed to be clean and well maintained, and most residents and staff reported that resident needs were met and staffing was sufficient.

The complaint was unsubstantiated. Allegations included unsafe, unhealthful, and uncomfortable accommodations and insufficient staffing to meet resident needs. Interviews and observations did not support these claims.

An unannounced complaint investigation was conducted in response to an allegation that staff discarded a resident’s personal items without authorization.

The investigation found that the allegations could not be substantiated based on interviews and statements. The issue was due to a miscommunication between the former resident and the facility, and the facility is implementing new systems to retain resident belongings left behind. No deficiencies were cited.

The complaint was unsubstantiated. The resident admitted to moving all items out prior to the scheduled move-out day and was satisfied with the facility's resolution, including prorated charges and a refund. The department determined there was insufficient evidence to prove the alleged violation occurred.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-11-29 regarding resident room security, planned activities, lighting, feeding assistance, and resident leaving the facility with assistance.

All allegations were found to be unsubstantiated after facility tours, interviews with staff and residents, and document reviews. The facility was observed to have unlocked resident room doors with appropriate egress systems, planned activities were offered and inclusive, lighting was sufficient, feeding assistance was provided as needed, and the facility attempted to assist a resident with leaving the facility but was limited by health and safety concerns.

The complaint investigation was unsubstantiated. Allegations included unlocked resident rooms, lack of planned activities, insufficient lighting, inadequate feeding assistance, and failure to assist a resident leaving the facility. Evidence did not support these allegations.

The visit was an unannounced case management incident inspection triggered by an incident report dated 12/12/2023 regarding a resident fall.

The inspection found no deficiencies. Resident 1 fell while trying to enter their apartment using a walker but was sent to the emergency room and returned with no additional orders or pain reported. The facility is conducting fall prevention training for staff.

Licensing Program Analyst Jamie Ivey Canady made an unannounced visit to conduct an annual inspection to ensure compliance with Title 22 regulations.

The facility was found to be in compliance with California Code of Regulations, Title 22 and Health and Safety Code, with no deficiencies cited at this time. The facility was sanitary, had adequate food supply, and resident and staff files were up to date.

The visit was an unannounced case management follow-up regarding an incident report received on 2023-11-21 about resident R1 having an unexplained laceration on the left leg.

No deficiencies were observed during the visit. The facility reported that R1 has recovered and the laceration was a skin tear. Documentation of R1's current condition was reviewed.

An unannounced annual inspection was conducted to ensure compliance with Title 22 regulations.

The facility was found to be in compliance with California Code of Regulations, Title 22 and Health and Safety Code, with no deficiencies cited at this time.

The inspection was conducted as an unannounced complaint investigation following allegations that staff physically abused a resident and failed to report the resident's condition in a timely manner.

The investigation found that the allegation of staff not reporting the resident's condition in a timely manner was unsubstantiated. However, the allegation that the resident was roughly handled by facility staff was substantiated, resulting in bruising to the resident. The facility conducted additional staff training on transfers and moving residents. An immediate civil penalty was assessed due to the substantiated finding.

The complaint was received on 09/14/2022 alleging staff physically abused a resident and failed to report the resident's condition timely. The allegation of physical abuse was substantiated, while the failure to report was unsubstantiated.

The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2022-08-29 regarding staff not wearing masks and failure to report COVID cases as required.

The investigation substantiated that on one occasion a staff member was not wearing a mask during their shift, posing a potential health and safety risk. The facility management addressed the issue with training. The allegation regarding failure to report COVID cases was unsubstantiated as the facility provided required information and statistical data to responsible parties and agencies.

The complaint investigation was substantiated for staff not wearing masks while on duty. The allegation that the facility administrator was not reporting COVID cases as required was unsubstantiated.

The visit was an unannounced complaint investigation conducted in response to an allegation that residents were being locked out of the facility due to being short staffed.

The investigation found no evidence to substantiate the allegation. Staff and residents reported no issues with leaving or reentering the facility, and procedures were in place to assist residents. Temporary Sunday entry restrictions had been lifted as of April 2022. The memory care unit doorbell response time averaged one minute, and COVID-19 screening policies were being followed.

The complaint alleged residents were being locked out of the facility due to short staffing. The allegation was unsubstantiated after investigation.

An unannounced annual inspection was conducted to ensure compliance with Title 22 regulations and to evaluate the physical plant of the facility.

The facility was found to be in compliance with California Code of Regulations, Title 22 and Health and Safety Code, with no deficiencies cited. The facility appeared sanitary, implemented COVID-19 safety measures, and had up-to-date employee and resident files.

The visit was an unannounced case management visit conducted to follow up on the facility's Plan Of Operation, which was not approved due to insufficient detail regarding care pricing levels and how care levels are determined.

The facility's submitted Plan Of Operation lacked a clear description of care levels and point value assignments, failing to meet regulatory requirements. Deficiencies were cited related to the Plan Of Operation and itemized charges, posing potential health and safety risks to residents.

The visit was conducted as a case management follow-up to review the facility's plan of operation and service plan documentation.

No deficiencies were cited during this unannounced case management visit conducted in response to follow-up on the facility's plan of operation.

An unannounced annual inspection was conducted to ensure compliance with Title 22 regulations and assess the physical plant of the facility.

The facility was found to be in compliance with California Code of Regulations, Title 22 and Health and Safety Code, with no deficiencies cited at this time. The facility appeared sanitary, implemented COVID-19 safety measures, and had an approved mitigation plan.

The visit was conducted as a case management visit to review the facility plan of operation and discuss issues on the submitted plan of operation.

No deficiencies were cited during this visit per Title 22 Regulations, Division.

The inspection was an unannounced complaint investigation visit triggered by multiple allegations including staff not properly trained, no one in charge when Administrator is away, and facility not following resident care plan.

The complaint regarding staff not properly trained was substantiated due to staff failing to wear face coverings properly, posing an immediate health and safety risk. The allegations that no one was in charge when the Administrator was away and that the facility was not following the resident care plan were found to be unsubstantiated.

The complaint investigation was based on allegations received on 09/09/2020. The substantiated allegation involved staff not properly trained, specifically a facility Director not wearing a mask properly during family tele-visits, confirmed by a screenshot and subsequent COVID-19 positive test of a resident. The unsubstantiated allegations included no one in charge when the Administrator was away and the facility not following the resident care plan regarding hearing aids.