Tracy's Boarding Care - Louise

Allegation investigated: Resident sustained an unstageable pressure injury while in care

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit to this facility to deliver the findings for the above allegation. LPA met with the Co-Administrator, Anabel Pascua and explained the reason for today’s visit. On 11/23/2021, the Department received a complaint alleging that Resident (R1) had sustained an unstageable pressure injury while in care. The complaint was referred to the Investigation Bureau (IB) on 11/23/21 but was rescinded due to involvement of Home Health Services for R1. The Department initiated the complaint investigation on 11/24/2021 at 9:43 AM. LPA conducted physical plant tour at 9:45 AM, obtained copies of the facility records relevant to the investigation at 10:00 AM and interviewed the Administrator and Home Health Nurse at 11:00 AM. (continued to LIC 9099-C) Unsubstantiated (continued from LIC 9099) It was alleged that Resident #1 (R1) was discharged from the hospital in September 2021 with Stage two pressure wounds and taken to the board and care. R1 was returned to the same hospital and was admitted on 11/17/21 with unstageable decubitus ulcer of the buttock. LPA’s record review on 04/10/22 of facility, hospital and home health records revealed that R1 was admitted to the facility on 07/31/21 with an initial diagnosis of colon cancer with the recommendation for Home Health for wound assessment, Ostomy Care, Caregiver Teaching and Physical Therapy. R1 was admitted by a home Health agency on 08/02/21 for various health issues including but not limited to a Stage 2 pressure ulcer. On 08/02/21, R1 was assessed by home health wound nurse to have a Stage 2 pressure sore on left buttock. R1 was put on three (3) Home Health nurse visits for the first week and two times a week for the next eight (8) weeks. Further review also revealed that R1 was on home Health services from 08/02/21 up to R1’s last hospitalization on 11/17/21 wherein R1 did not return to the facility and was placed in a Skilled Nursing Facility. Further review also confirmed that caregivers of the facility were educated on how to care for R1’s wound and in general by the Home Health Nurse (HHN). LPA’s interview with HHN on 11/24/21 at around 11:30 AM confirmed that the HHN was at the facility caring for R1 and was the one who called 911 due to R1’s behavior on 11/17/21 when R1 was hospitalized. Further, HHN confirmed training the staff on how to provide care for R1. LPA’s interview with staff on 04/12/22 at 10:52 AM revealed that the staff change R1’s diaper on a regular basis and turned R1 every two (2) hours as instructed. Based on the information gathered during the course of the investigation, there is insufficient information to support the allegation and therefore deemed unsubstantiated at this time. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, Oct 27, 2023 · control 31-AS-20211123104538

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Gary Tan, met administrator Anabelle Pascua for a One (1) Year Required visit for this facility. LPA explained the reason for the visit. A tour of the physical plant was conducted at 12:29 PM and the following was noted: There is only one entrance being utilized at the facility, there are required poster posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Infection Control and Mitigation plan. Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside and inside. 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 visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room. The facility has seven (7) bedrooms and three (3) bathrooms currently occupying six (6) residents. One (1) bedroom is designated for staff use. The facility is fire cleared for six (6) non-ambulatory residents, all six (6) of them may be bedridden. Hospice waiver for two (2). Living and dining room furniture were also checked. The living room is neat and clean. The facility maintains a comfortable temperature at 76°F. The smoke detectors are hardwired and interconnected and observed to be operational. There is a carbon monoxide installed at the facility. Fire extinguisher is located in the kitchen and observed to be full and last inspected on 05/03/23. The backyard of the facility has outdoor furniture, with a covered shaded area for clients. The swimming pool is fully covered and appropriately fenced. (continued on LIC 809-C) (continued on LIC 809-C) There is no garage at the facility, only car port located at the back. The backyard has a locked shed being used as a tool shed and old equipment storage. Laundry room is located at the back yard by outside activity area. Laundry detergents, cleaning agents and other toxins are stored in a locked cabinet in the storage. Food Service/Kitchen area was sufficiently stocked with 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 in a kitchen drawer and inaccessible to residents. The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hall ways/passage ways are lit. Clients have sufficient amounts of personal hygiene product which is provided by the licensee. Staff Rooms: Staff room was observed to be locked. No medications are observed in the staff room. The bathroom was checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the toilet and shower. The hot water temperature was measured a range of 106.3°F to 110.9°F. Towels and washcloths are not shared. There was enough clean linen available in stock at the cabinet. Medications: LPA observed medication in the hallway cabinet to be locked and inaccessible to residents. There were two (2) complete first aid kits located at the medication cabinet. Client records: Client records are reviewed. Client records appear to be complete and updated. Staff records: LPA conducted a complete file review of staff records. Staff records appeared to be complete and updated. Disaster drill was last conducted on 08/01/23. Required posting observed in facility (complaint hot line poster). Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Aug 6, 2023

Type of visit: Required - 1 Year

On 06/21/22 at 9:40 a.m Licensing Program Analyst (LPA) Joscelyn Martinez arrived at the facility to conduct an unannounced annual inspection. Upon arrival LPA met with staff and then met with Administrator Designee Annabelle Pascua. The purpose of the visit was explained. Entrance interview conducted. A physical plant tour was conducted at 9:50 a.m and the following was observed: Infection Control: Covid-19 infection control signage were observed outside of the facility. Proper signage was also observed inside in the common areas. Staff screened LPA for covid symptoms and took LPA’s temperature. Facility has sufficient PPE supplies for more than 30 days. Food Inspection/Kitchen: LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers in the kitchen. Sharps are centrally stored in a locked area. Medication are centrally stored in a locked cabinet in the kitchen area. Smoke detectors/carbon monoxide are located throughout the facility and are dual hardwired. Smoke detectors and carbon monoxide detectors were tested at approximately 10:05 a.m. and appear to be functional. Fire extinguisher has a purchase date of 04/11/2022. Common Areas: All common areas were observed to be clean and properly furnished. Facility’s temperature at the time of the visit was 81F. Resident Rooms: Facility has seven (7) bedrooms which of six (6) are designated for resident use. Facility has two live-in staff. All seven (7) bedrooms were toured and appear to be clean and properly furnished. LPA observed additional bedding and linens sufficient for all of the residents. All rooms have adequate lighting and furniture. Bathrooms: There are three (3) bathrooms in the facility of which two (2) are designated for resident’s use. LPA observed all bathrooms to be cleaned. At 9:54 a.m LPA toured the bathroom next to bedroom number three (3). LPA observed a can of cleaning supply under the bathroom sink. LPA asked staff to immediately remove the cleaning supply and store it in the locked cabinet located under the kitchen sink. The hot water was tested and measured 106.5 F, which is in regulation. All trash cans located in the bathrooms had tight fitting lids. (Continue on 809-C) Outside: LPA toured the outside area and observed appropriate outdoor furniture with a shaded covered area for residents. There is a shack located outside that is used for additional storage and laundry chemicals storage. The laundry area is located outside. There is a body of water that has a wooden cover and a gate around the pool making it inaccessible to residents. The following deficiency were observed and cited per Title 22 see attached LIC809D. Exit interview conducted. Report signed and delivered. Appeal rights delivered.the state’s words, verbatim · CDSS document, Jun 21, 2022

From the deficiency page — Deficiency type: Type A · Plan of correction due date: Jun 22, 2022

Care of Persons with Dementia 87705 (f) (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 Based on observation, the licensee did not comply with the section cited above in ensuring cleaning supplies are inaccessible to residents which poses immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 21, 2022

Allegation investigated: Resident developed an unstageable pressure injury while in care.

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit to this facility to deliver the findings for the above allegation. LPA met with the Assistant Administrator Annabel Pascua and explained the reason for today’s visit. During the initial visit on 08/10/2021 at 9:15 AM, LPA Alex Pitz obtained copies of the facility records, interviewed Staff and Administrator. Investigation Branch (IB) Investigator Peter Zertuche also conducted a separate investigation regarding the same allegation. During the course of investigation, Investigator Zertuche interviewed nurse from the palliative care services agency, facility staff and resident and obtained medical record from the hospital. Regarding the allegation that a resident had developed an unstageable pressure injury while in care, it was alleged that Resident #1 (R1) had an unstageable pressure sore when visited by a palliative care nurse on 08/04/21. (continued to LIC 9099-C) Substantiated (continued from LIC 9099) IB Investigator Vasquez interview with the nurse on 08/26/21 at about 2:30 PM, revealed that the nurse discovered R1 to have unstageable ulcers on left heel and coccyx area, the nurse added that R1 was not in hospice care nor there is a prior hospice care or home health services for R1. The nurse referred R1 to hospice care but the family member of R1 refused. Further interview with the nurse also revealed that the facility did not inform the palliative care agency nor the hospital to inform of R1’s pressure sore condition prior to or immediately after the nurse’s visit on 08/04/21. It was only on 08/09/21 that the facility brought R1 to the hospital without being treated at the facility. Investigator Zertuche’s interview with the administrator on 09/16/21 at around 12:00 PM, revealed that R1 was not brought to the hospital nor the facility contracted a hospice agency to care for R1’s wound because R1’s family member refused to do so. Moreover, Investigator Zertuche’s interview with two (2) care staff on 09/16/21 at 12:30 PM and 1:00 PM respectively, revealed that R1 was not being checked and/or changed diapers regularly, especially during nights. Investigator Zertuche’s medical record review on 08/26/21 at around 5:00 PM revealed that R1 had stage 3 pressure sore on coccyx and unstageable pressure sore on left heel. Based on the information gathered during the course of the investigation, including interviews, and record review between 08/26/21 and 09/16/21, R1 developed pressure sore (Unstageable and Stage 3 pressure injuries) while in care. Therefore, the allegation is deemed substantiated at this time Citation issued, appeal rights discussed and given. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, Jun 19, 2022 · control 31-AS-20210809091844

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Jun 20, 2022

Prohibited Health Condition (a) Persons who require health services for or have a health condition including, but not limited to, those specified below, shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not ensure that R1 was not retained with a Stage 3 or 4 pressure injury and received proper treatment of the pressure injury, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 19, 2022

Plan of correction: Administrator agreed to review regulations related to prohibited and restricted health conditions and send a written statement of understanding to CCL. Administrator and staff will complete a training on pressure injuries and proof of training will be sent to CCL on or before the POC date

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Pitz conducted an unannounced visit on this day in response to complain # 31-AS-20210809091844. At approximately 9:15 a.m. LPA arrived at the facility and was greeted by staff and allowed entry. LPA observed that Staff #1 (S1) and Staff #2 (S2) were in the process of changing/ bathing Resident 1 (R1). LPA asked S1 if R1 had any wounds and they said "no, just colostomy." LPA asked R1 if they had any wounds and they said that they "have some wounds on [their] butt." At 10:45 am LPA asked administrator if staff were providing any wound care or colostomy care to R1 and they said "No, only I or home health provide colostomy care." Administrator denied that R1 had any pressure injuries at this time. LPA asked if there were any Home Health records for either wound care or colostomy care and she said "no, everything is digital now with them." At 10:50 am LPA observed the facility's care notes for R1 on 8/3/21 to indicate that R1 has a "bedsore stage 2." Report reviewed, signed and delivered. Exit interview conducted, deficiencies on 809D.the state’s words, verbatim · CDSS document, Aug 10, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87609(B)(4) · Plan of correction due date: Aug 17, 2021

87609(B)(4) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident’s medical condition(s). This requirement is not met as evidenced by: Based on observations and interviews, the facility did not ensure that a written record of the Home Health agreement for wound care of R1 was kept at the facility which poses an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Aug 10, 2021

Plan of correction: Administrator will provide proof of a Home Health agreement being in place for R1

From the deficiency page — Deficiency type: Type A · Section cited: CCR87621(b)(1)(B) · Plan of correction due date: Aug 17, 2021

87621(b)(1)(B) There shall be written documentation by an appropriately skilled professional outlining the instruction of the procedures delegated and the names of facility staff who have been instructed. This requirement is not met as evidenced by: Based on observations and interviews, the facility did not ensure that written documentation of the colostomy care being provided by Home Heatlh was kept on file which poses an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Aug 10, 2021

Plan of correction: Adminsitrator will provide proof of an appropriate written care plan being developed by the facility and an appropriately skilled professional.