Westminster Gardens

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Ashley Calderon conducted a site visit for the Required - 1 Year inspection, using the CARE Tool. Today's visit is a continuation annual inspection case management. Upon arriving at the facility, LPA met with Director of Wellness Sev Tienda. The facility is licensed to serve for a capacity of two hundred (200) Non-ambulatory residents ages 60 and above. The facility has an approved Hospice Waiver on file for six (6) residents. The facility also has an approved Dementia Care plan. This is a Continuing Care Retirement Community (CCRC) which includes separate buildings throughout the premises. The Assisted Living residents are located in the Memorial Lodge (ML) and Shu Lodge (SL). Memory Care residents are located in the Hacienda Building. There are currently 32 residents residing in Assisted Living, 9 residents in Memory Care and 122 residents in Independent Living. Two residents on Hospice. On today's visit LPA interviewed 4 staff and 5 residents. LPA along side with Teresita Bastes and Sev Tienda reviewed a total of 5 resident medication and medication administration records and no deficiencies noted. LPA Calderon along side with Veronica Davila/ Human Resource Director, reviewed a total of 5 staff files, all staff are cleared and appropriate documentation in files. No deficiencies were observed during today's visit. An exit interview was conducted and a copy of this report was provided to Sev Tienda via email at eusebio.tienda@humangood.org (due to printer issues).the state’s words, verbatim · CDSS document, Jun 16, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced site visit for the Required - 1 Year inspection, using the CARE Tool. Upon arriving at the facility, LPA met with Director of Wellness Sev Tienda and Health Services Administrator Jose Antonio "Tony" Agoncillo who assisted with the visit. The facility is licensed to serve for a capacity of two hundred (200) Non-ambulatory residents ages 60 and above. The facility has an approved Hospice Waiver on file for six (6) residents. The facility also has an approved Dementia Care plan. This is a Continuing Care Retirement Community (CCRC) which includes separate buildings throughout the premises. The Assisted Living residents are located in the Memorial Lodge (ML) and Shu Lodge (SL). Memory Care residents are located in the Hacienda Building. There are currently 32 residents residing in Assisted Living, 9 residents in Memory Care and 122 residents in Independent Living. Two residents on Hospice. LPA toured the physical plant areas inside and outside. LPA toured facility with Sev, Tony and staff Gary Walter/ Building and Grounds staff. Random rooms were selected. LPA in Memorial Lodge toured room 3, 8,16. Memorial Lodge had office room, laundry room, and barber shop locked and inaccessible to residents in care. LPA toured in the Shu Lodge toured rooms 1, 4, activity room, janitor room contains chemicals and disinfectants (locked), and 4 storage closets containing linen, towels and storage supplies inaccessible to clients in care. LPA observed Memory care room 3 and 6, activity room and staff room, building had delayed egress system in place. Resident rooms were furnished appropriately. Each resident room has their own bathroom. The bathrooms were observed to be clean and operational w/grab bars and showers/bathtubs had non skid coating tiles, mats, strips or ridges. The hot water temperature was tested throughout the facility and measured within Title 22 Regulation guidelines. Rooms had emergency call systems in residents bathrooms, and residents had pendants. LPA observed wellness room, medications were maintained locked in medication carts. LPA observed and tested operable carbon monoxide detectors in facility buildings. Pull fire alarms and fire extinguishers (charged and serviced) were located through the facility. Last fire drill conducted on 5/23/23. (Continuation on LIC 809-C...) The front grounds of the facility are well landscaped and have a leveled walkway to the entrance. There are various yard areas throughout the facility that are equipped with patio furniture / shading for resident comfort and safety. LPA observed pond which does not exceed a few inches of water and outdoor grounds were well landscaped. Facility has a working landline. The kitchen was observed. There was a sufficient amount of perishable and non-perishable food supplies. Food menu observed posted in Morrison House, Online Portal and provided to residents. Activity calendar posted. Sufficient PPE observed. Liability insurance expires on 1/1/2024. Administrator Certificate renewal for Andrew Smith pending, LIC 9214 submitted for renewal. Valerie Garcia Director of Hospitality, Admin. Certificate Expires on 10/12/24. No deficiencies were observed during today's visit. Visit will need to be continued due time restraint, interview was conducted and a copy of this report was provided via email at eusebio.tienda@humangood.org (printer issues)the state’s words, verbatim · CDSS document, Jun 15, 2023

The state marks this report as 5 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Allegation #5 - Facility did not uphold resident's rights to make choices concerning their dally life in the facility.

During the course of the investigation into the factors surrounding this allegation, it was determined that the Resident was free to make choices concerning daily life activities. Additionally, the resident's spouse took resident out of community on multiple occasions including choosing to take him to Adult Day Care center to participate in activities with other participants during the day. It has also been determiend that the Resident's spouce contacted the Wellness Office asking for assistance with care for her husband. The resident was then transferred temporarily to Bridge Care in Assisted Living to ensure that the appropriate level of care was provided. Allegation Finding: Unsubtantiated. The Department was unable to obtain evidence to support this allegation. A complaint allegation finding of Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 25, 2022 · control 28-AS-20220502074202

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Allegation #3 - Facility did not inform resident's representative about ongoing evaluations.

Facility informed resident’s representative about ongoing evaluations and included representative and others as desired by representative. Documents capturing multiple conversations and verification of assessment reviewed. Facility informed resident and resident’s representative about ongoing evaluations and process for determining care transitions in the resident’s residency agreement. Allegation Finding: Unsubtantiated. The Department was unable to obtain evidence to support this allegation. A complaint allegation finding of Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 25, 2022 · control 28-AS-20220502074202

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Allegation #4 - Facility did not uphold resident's right to leave and depart the facility freely and not be locked into a room.

During the course of the investigation into the factors surrounding this allegation, it was determined that there were multiple episodes of resident wandering in hallways and into other resident rooms. Resident was redirected to leave the resident rooms. Resident also had multiple episodes of exit-seeking behavior. Spouse was informed and gave consent for a Wander Guard. A Physician’s order obtained for Wander Guard due to residents wandering in order to protect the resident from harm to himself and/or others. Allegation Finding: Unsubtantiated. The Department was unable to obtain evidence to support this allegation. A complaint allegation finding of Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 25, 2022 · control 28-AS-20220502074202

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Allegation #1 - Facility did not provide a 60 day written notice for rate increases and increases in any rate structure for services as stated in the admission agreement.

Interviews conducted and documents reviewed reveal that the community provided written notice for rate increases and rate structures. The annual rate increase letter was provided on November 1, 2021 with new rates effective January 1, 2022. Facility also provided written notice of other rate structures (optional rate fees) including Mr. Milner’s bridge care stay in Assisted Living. Allegation Finding: Unsubtantiated. The Department was unable to obtain evidence to support this allegation. A complaint allegation finding of Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 25, 2022 · control 28-AS-20220502074202

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Joe Katrdzhyan conducted a site visit for the Required - 1 Year inspection. Upon arriving at the facility, LPA met with Executive Director / Andrew Smith and was later joined by the Director of Wellness / Sev Tienda, who assisted with the visit. The facility is licensed to serve for a capacity of two hundred (200) Non-ambulatory residents ages 60 and above. The facility has an approved Hospice Waiver on file for six (6) residents. The facility also has an approved Dementia Care plan as part of their operation. This is a Continuing Care Retirement Community (CCRC) which includes two separate levels of care; Independent Living and Assisted Living. The Assisted Living residents are located in the Memorial Lodge (ML) and Shu Lodge (SL). Memory Care residents are located in the Hacienda Building. There are currently 24 residents residing in Assisted Living, 9 residents in Memory and 127 residents in Independent Living. The facility does NOT have a bedridden fire clearance. During today's visit, LPA used the infection control domain to complete the Required - 1 Year inspection. Also, the physical plant was toured, medications and food supplies reviewed. LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. During the tour, LPA was accompanied by Mr. Tienda and Director of Grounds / Gary Walter. LPA toured a random selection of resident rooms. Resident rooms were furnished appropriately. Each resident room has their own bathroom. The bathrooms were observed to be clean and operational w/grab bars. The hot water temperature was tested throughout the facility and measured within Title 22 Regulation guidelines. The facility has central air and heating accommodations. The front grounds of the facility are well landscaped and have a leveled walkway to the entrance. There are various yard areas throughout the facility that are equipped with patio furniture for resident comfort and safety. (Please see LIC 809C for additional information) Facility has a working landline. The kitchen was observed. There was a sufficient amount of perishable and non-perishable food supplies. No pesticides or poisons were stored in the food areas. Medications are centrally stored and locked in each of the lodges/buildings stated on this report. All required information (COVID-19, Emergency Exiting Floor Plan, Personal Rights, Ombudsman information, Theft and loss policy and Emergency Telephone Numbers) are posted in the facility. During today's walk through, LPA observed COVID-19 prevention/protocol signs posted throughout the facility. LPA reviewed resident medications. The following concerns were observed during today's visit; At 11:42am, LPA found a scissor in the kitchen cabinet located at the Hacienda Building, left accessible to memory care residents. At 11:50am, LPA tested the delay egress doors (two doors) located inside the Hacienda building and once the doors opened and the alarm sounded off, facility staff were unable to deactivate the noise using the key pad, located by both delay egress doors. The noise sounded off until maintenance had to disconnect the wires. At 12:05pm, LPA discovered that medications Atenolol 50 mg tablet (50 mg by mouth once daily), Losartan 25 mg tablet (25 mg by mouth daily), Simvastatin 10 mg tablet (10 mg by mouth once daily) and Vitamin B-12 1,000 mcg tablet (1,000 mcg by mouth once daily) were missing from the facility and not being administered to Resident 1 (R1), by facility staff, per physician's instructions. The following deficiencies were observed to be in violation of California code of Regulations, Title 22, Division 6 (refer to 809D) An exit interview was conducted and a copy of this report was provided along with the Appeals Rights.the state’s words, verbatim · CDSS document, Aug 17, 2022

From the deficiency page — Deficiency type: Type A · Plan of correction due date: Aug 17, 2022

87705 Care of Persons with Dementia. 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: At 11:42am, LPA found a scissor in the kitchen cabinet located at the Hacienda Building, left accessible to memory care residents. This poses an immediate health and safety concern for the residents in care.the state’s words, verbatim · CDSS document, Aug 17, 2022

From the deficiency page — Deficiency type: Type A · Plan of correction due date: Aug 18, 2022

87303 Maintenance and Operation. 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: At 11:50am, LPA tested the delay egress doors (two doors) located inside the Hacienda building and once the doors opened and the alarm sounded off, facility staff were unable to deactivate the noise using the key pad, located by both delay egress doors. The noise sounded off until maintenance had to disconnect the wires.the state’s words, verbatim · CDSS document, Aug 17, 2022

From the deficiency page — Deficiency type: Type A · Plan of correction due date: Aug 18, 2022

87465 Incidental Medical and Dental Care.. The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: At 12:05pm, LPA discovered that medications Atenolol 50 mg tablet (50 mg by mouth once daily), Losartan 25 mg tablet (25 mg by mouth daily), Simvastatin 10 mg tablet (10 mg by mouth once daily) and Vitamin B-12 1,000 mcg tablet (1,000 mcg by mouth once daily) were missing from the facility and not being administered to Resident 1 (R1), by facility staff, per physician's instructions. This poses an immediate health and safety concern for the resident in care.the state’s words, verbatim · CDSS document, Aug 17, 2022

Allegation investigated: Staff failed to respond to resident's medical needs resulting in hospitalization Facility staff failed to follow Physician's orders

Licensing Program Analysts (LPAs) Joe Katrdzhyan and Nune Margaryan conducted an unannounced follow up visit to this facility to deliver findings on the above mentioned allegations of "Staff failed to respond to resident's medical needs resulting in hospitalization" and "Facility staff failed to follow Physician's orders". Upon arriving at the facility, LPAs met with Staff / Ana Cortez and Erica Cox and were later joined by Director of Wellness / Eusebio "Sev" Tienda who assisted with the visit. LPA Katrdzhyan conducted a prior visit to this facility on 1/16/2020, in reference to the allegations listed above. During the course of the investigation, LPA conducted interviews of various persons to include the Previous Administrator / Michael Walper, Previous Director of Wellness / Martha Cruz, LVN 1, LVN 2 and Resident 1 (R1). LPA made an attempt to interview LVN 3 but was unsuccessful. LPA also reviewed and obtained copies of the following documents in reference to R1; • Resident Cover Sheet • Identification and Emergency Information Sheet • Discharge Instructions from Royal Oaks Skilled Nursing • Interdisciplinary Notes for period 11/22/19 - 12/6/19 • Physician's Order dated 12/3/19 Unsubstantiated requesting Physical Therapy • Log for Checking on Residents every 2 hours for period 11/22/19 - 12/6/19 • Physician's Report • RCFE Resident Appraisal. The investigation revealed the following; Allegation: Staff failed to respond to resident's medical needs resulting in hospitalization. The details of the allegation states that on the evening of 10/18/19, R1's daughter called R1 and based on their conversation she determined that R1 was not in the right state of mind. R1's daughter called the reception desk in Independent Living asking staff to check on R1. According to R1's daughter, staff did not check on R1. The following day, R1's friend came to the facility and found R1 in her bed at 1PM unable to move or speak coherently. R1's friend called 911 and R1 was taken to the hospital. Based on the interview of LVN 2, LVN 2 could not recall receiving a call from the daughter of R1 asking to check on R1's condition. Staff interviewed stated that residents are checked each time a call is made by family requesting a staff member to check on a resident. Based on the interview of LVN 1, LVN 1 denied having knowledge of R1 not feeling well on 10/19/19. During her shift on 10/19/19, LVN 1 stated that she was surprised to see the paramedics arrive at the facility asking to see R1. LVN 1 escorted paramedics to R1's room finding R1 and R1's friend inside the room. According to LVN 1, R1's friend did not call staff for help and called 911 upon discovering R1 was not feeling her usual self. Based on interviews conducted, LPA learned that staff in Independent Living (IL) have a way of monitoring the IL residents. It's called "keeping an are you okay check" on the residents, which residents have to push the are you okay button (from their rooms) between the hours of 5am – 10am. If a resident fails to push the are you okay button by 10am, the computer generates a list of residents which staff will need to contact ensuring the resident well being. If there is no answer, staff will go in person and check on the resident in their apartment. In the case of R1, R1 had pressed the are you ok button in the morning alerting staff that everything was okay. During the interview of R1, R1 could not recall the incident other than waking up at the hospital on 10/19/19. In reference to her stay at Westminster Gardens, R1 stated that "this is a great place to live, staff Is helpful and the people are wonderful". Based on interviews conducted, there is insufficient evidence to support the allegation of Staff failed to respond to resident's medical needs resulting in hospitalization. Allegation: Facility staff failed to follow Physician's orders. The details of the allegation states the facility took three weeks to begin physical therapy. Based on the file review for R1 and interviews conducted, the following information was gathered. (Please see LIC 9099C for additional information) On 10/19/19, at 12:30PM, R1 was hospitalized at Methodist Hospital. On 10/25/19, R1 was transferred to Royal Oaks Skilled Nursing. On 11/22/19, R1 was transferred from Royal Oaks Skilled Nursing to Westminster Gardens Assisted Living, under respite care. On 12/6/19, R1 was discharged from Assisted Living respite care to her Independent Living apartment at Westminster Gardens. After reviewing the discharge instructions dated 11/22/19 from the treating physician, LPA discovered that there was no written order for physical therapy (PT) for R1. On 12/5/19, it is noted that R1 was visited by Concord Home Health and R1 will have a PT evaluation and treatment. Based on interviews conducted and record review, there is insufficient evidence to support that Westminster Gardens failed to follow physician's orders for PT in reference to R1. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 22, 2021 · control 28-AS-20200107153321