Elder Creek Villa

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Abeye Duguma met with Assistant Administrator Jesse Manuel for a One (1) Year Required - Infection Control visit. LPA explained the reason for the visit. A tour of the physical plant was conducted at 9:30am and the following was noted: There is one entrance being utilized at the facility, there are required posters posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, infrared thermometer, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing masks upon entrance and during the visit. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated outdoor visitors' area located in backyard. The facility has sufficient stock of PPE in a storage cabinet located in the kitchen. The facility has a total of six (06) bedrooms for residents, one (01) for staff and two (02) bathrooms for both residents and staff. The facility is fire cleared for six (06) non-ambulatory and a hospice waiver for two (02). The facility is currently occupying six (06) non-ambulatory residents of which one (01) is on hospice care. The facility has outdoor furniture with a covered shaded area (umbrella) for residents. The facility does not have a swimming pool/body of water. The garage is being used for storage and laundry. Laundry detergents, cleaning agents and other toxins are stored in the locked garage. Kitchen area was sufficiently stocked with at least two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked and inaccessible to residents. The living and dining room are neat and clean. The facility maintains a comfortable temperature at 75°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. (continued on LIC 809-C) Fire extinguisher is located in the kitchen, observed to be full and last purchased 12/31/2021. The facility is equipped with a fire sprinkler system. The residents' rooms are adequately furnished with appropriate lighting system. Hallways are well lit. Residents have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 113.3°F. Towels and washcloths are not shared. There was enough clean linen available in the cabinets. LPA observed medication and first aid kit to be locked and inaccessible to residents. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, May 17, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Abeye Duguma met with the Assistant Administrator, Jesse Manuel for a One (1) Year Required - Infection Control visit for this facility. LPA explained the reason for the visit. A tour of the physical plant was conducted at 9:50am and the following was noted: There is one entrance being utilized at the facility, there are required posters posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, infrared thermometer, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing masks upon entrance and during the visit. Signs to wear masks and other COVID 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated outdoor visitors' area located in backyard. The facility has sufficient stock of PPE in a storage cabinet located in the kitchen. The facility has a total of six (06) bedrooms for residents, one (01) for staff and two (02) bathrooms for both residents and staff. The facility is fire cleared for six (06) non-ambulatory and a hospice waiver for two (02). The facility is currently occupying six (06) non-ambulatory residents. The facility has outdoor furniture with a covered shaded area (umbrella) for residents. The facility does not have a swimming pool/body of water. The garage is being used for storage and laundry. Laundry detergents, cleaning agents and other toxins are stored in the locked garage. Kitchen area was sufficiently stocked with at least two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. (continued on LIC 809-C) Knives and sharps are observed to be locked in a cabinet inaccessible to residents. Living and dining room furniture were also checked. The living and dining room is neat and clean. The facility maintains a comfortable temperature at 76°F. The smoke detectors are hardwired, interconnected and observed to be operational. The facility is equipped with fire sprinklers. The carbon monoxide detector is also operational. Fire extinguisher are located in the kitchen, observed to be full and purchased on 01/07/2021. No medications are observed in the staff room. The residents' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are well lit. Residents have enough personal hygiene products provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 101.3°F. Towels and washcloths are not shared. There was enough clean linen available in the hallway cabinet. LPA observed medication and first aid kit to be locked and inaccessible to residents, located in the kitchen. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Dec 23, 2021

Allegation investigated: Staff storing expired food. Facility not allowing visitors. Chemicals are accessible to resident's. Facility not following proper infection control process to prevent the spread of COVID-19

This is an amended report. It takes the place of the report issued on 5/13/2021. Findings remain the same. Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced initial complaint visit to investigate the allegations above. Upon entry to the facility, LPA met with facility staff and explained the reason for this visit. LPA spoke with the administrator Alfredo Rapisura by telephone at approximately 10:05 am and explained the reason for this visit. Staff storing expired food It is alleged that on 4/28/21 facility was observed to have expired food in the refrigerator such as yogurt and peanut butter. At approximately 10:15am, LPA conducted a physical plant walk through of the facility which included the kitchen. LPA checked the food supply. At approximately 10:25 am, LPA conducted an interview with staff who shared that they did have food that was expired in the refrigerator that was thrown away when brought to their attention. Based upon the information obtained through interviews this allegation is deemed Substantiated. Substantiated Facility not allowing visitors It is alleged that the facility is not allowing visitors at this time. Upon entry to the facility at 10am, LPA noticed a posting on the door that stated that facility was restricting visiting to only essential healthcare personnel. At 10:05 am, LPA spoke with the administrator regarding the posting and he stated that they do allow visits to be scheduled. LPA explained that what is posted on the entry door to the facility contradicts the visiting policy. Based on information obtained through observation this allegation is deemed Substantiated. Administrator did state that the posting would be removed from the door. Chemicals are accessible to resident's. It is alleged that on 4/28/21 cleaning solution was accessible to residents in the bathroom. During the physical plant walk through at 10:15am, LPA spoke with facility staff who confirmed that this did happen and that the cleaning solution was locked away immediately. Based on information obtained through interviews this allegation is deemed Substantiated. Facility not following proper infection control process to prevent the spread of COVID-19 It is alleged that facility does not properly screen visitors prior to entry to the facility or take any temperatures prior to visitors entering the facility. Upon entry to the facility at 10:am, LPA was not screened or did anyone take LPA's temperature. LPA was also informed the facility did not have any more personal protection equipment (PPE). Based upon the information obtained through observation and interviews this allegation is deemed Substantiated. All deficiencies cited on LIC 9099 D. Appeal Rights explained. Exit Interview conducted. Copy of report emailed for signature.the state’s words, verbatim · CDSS document, May 13, 2021 · control 31-AS-20210506145942

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: May 17, 2021

Personal Rights-To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on observation the facility fails to do a properly screen visitors or take temperatures of visitors upon entry to the facility which can pose a potential health and safety risk to residents in the facility.the state’s words, verbatim · CDSS document, May 13, 2021

Plan of correction: Administrator shall have an in-service training with staff on the importance of screening all visitors and taking temperatures of everyone entering the facility. Copy of the in-service sign in sheet will be submitted to clear the citation.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(11) · Plan of correction due date: May 17, 2021

Personal Rights- To have their visitors permitted to visit the facility privately during reasonable hours. This requirment was not met as evidenced by: Based on observation the facility has a sign upon entry that states all visits are restricted unless you are an essential healthcare worker. This poses a personal rights issue to residents in care by not allowing them to have visitors.the state’s words, verbatim · CDSS document, May 13, 2021

Plan of correction: Administrator shall take the signage down regarding visiting to the facility and update it to correctly show the current visiting policy. Administrator shall contact residents responsible persons and inform them of the updated visiting policy. Self certification will be sent to LPA once this is done to clear this citation.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555 · Plan of correction due date: May 13, 2021

General Food Service Requirements-All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement was not met as evidenced by: Based on information obtained through interviews on 4/28/21 facility had expired food stored in the refrigerator which posed a potential health and safety risk to the residents in care.the state’s words, verbatim · CDSS document, May 13, 2021

Plan of correction: Corrected before visit. Expired food was thrown out.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(f)(2) · Plan of correction due date: May 13, 2021

Care of persons with Dementia- The following should be stored inaccessible to residents that have dementia cleaning supplies and disinfectants. This requirement was not met as evidenced by: Based on interviews conducted on 4/28/21 cleaning solution was found accessible to residents in care which posed as a health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 13, 2021

Plan of correction: Corrected before visit. The cleaning solution was immediately locked away.