Woodland Hills Retirement Home

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angel Ascencio arrived at the facility unannounced to conduct a required annual visit at 9:35 a.m..The LPA met with staff and explained the reason for the visit. The Administrator Serguei Kalistratov arrived shortly thereafter. The LPA, with the guidance of staff, 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. BEDROOMS: All client rooms are set up with beds, night stands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds. In addition, no bedroom was used as a passageway to another room, bath or toilet. There are six (6) total bedrooms for resident use – all resident rooms are private rooms. RESTROOMS: There are two (2) total bathrooms at the home. The resident bathroom has a shower with non-skid materials. The toilet and shower have grab bars. During the visit, the LPA observed signs in all of the bathrooms pertaining to proper hand hygiene. All cleaning supplies were inaccessible to client in care. In addition, restroom hot water measured under 120.0 degree F. KITCHEN: Kitchen knives are stored in a locked closet by the kitchen. The supply of dishes, utensils, pots, pans and drink ware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. Continued on LIC 809 - C The supply of perishable and nonperishable food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. Kitchen, laundry and house cleaning supplies are stored in a locked cabinet. No flies or other vermin were observed. Hot water in kitchen was measured at 104.0 degrees Fahrenheit. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, common seating area and dining room furniture was observed to be in good condition. Chairs were observed to be at least 6 (six) feet apart for social distancing. The LPA observed the required postings in the common hallway. Fire extinguishers were observed to be serviced within the last year. The facility smoke alarm system is hardwired and operated normally at the time of visit. Medications were observed to be locked in a closet by the kitchen and contained at least 30 days of worth of medication. The garage door was observed and contained a locked cabinet for laundry supplies. The backyard has a covered outdoor area equipped with furniture for client use. There were no bodies of water noted. INFECTION CONTROL: During today’s visit, the LPA spoke with the Staff regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time and the LPA reviewed facility’s policies and procedures as it pertains to infection control. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Starting at 10:01 a.m., during resident file review, five (5) out of six (6) residents did not have their Needs and Service Plan signed by the residents responsible party. In addition, one (1) resident did not have a current Needs and Appraisal based on Change in Condition. Continued on LIC 809 - C At 10:20, during resident file review, LPA did not observe bed rail orders for three (3) out of the five (5) resident. At 10:47 a.m., during resident file review, one (1) resident did not have Tuberculosis test documented. At 11:00 a.m., LPA did not observed quarterly emergency drills. At 12:00 p.m., during staff file review, all staff member (7) did not have their initial 40 hours of training and their continued 20 hours annually. In addition, LPA did not observe Dementia required training for all staff. At 12:30 p.m, during staff file review, six (6) Staff did not have a their Tuberculosis documented. At 3:00 p.m., during medication review, LPA did not observe PRN Authorization Form for six (6) out of 6 residents. Administrator Serguei Kalistratov could not join the LPA for exit interview, but authorized staff member to sign the documents. Exit interview conducted and copy of the report and appeal right were issued.the state’s words, verbatim · CDSS document, May 10, 2023

Allegation investigated: Staff failed to assist resident with the self-administration of medication Staff failed to refill resident's presciptions in a timely manner

Licensing Program Analyst (LPA) Elsie Campos conducted a subsequent complaint visit to this facility. The LPA met with staff Irina Fried and explained the reason for the visit. The Administrator Serguei Kalistratov arrived shortly thereafter. During the initial visit conducted on 3/1/2022, LPA’s Elsie Campos and Ashley Smith interviewed a resident's responsible party at 2:44 p.m., interviewed residents at 1:45 p.m., and 1:59 p.m., and, interviewed staff at 3:12 p.m., 3:27 p.m. and 3:46 p.m. The LPA's also obtained documents pertinent to the investigation. During a subsequent visit on 8/3/2022 the LPA, interviewed staff at 3:10 p.m. and 3:18 p.m., interviewed residents at 3:30 p.m., 3:40 p.m. and 4:15 p.m., obtained additional documents at 4:28 p.m. and delivered findings on four out of six allegations. During today’s visit the LPA conducted a medication audit at 11:45 a.m. and delivered findings on two allegations. Continued on LIC9099-C Unsubstantiated Regarding the allegation: Staff failed to assist resident with the self-administration of medication It was alleged that staff, are not providing Resident #1 (R1) with all their medications. During today’s visit the LPA was unable to review the Medication Administration Record (MAR) for R1 as no records were available. Staff indicated that the MAR is not something they normally complete and only complete the Centrally Stored Medication logs. A review of the centrally stored medication log for Resident #1 (R1) revealed that R1’s medications were logged but because R1 is no longer a resident at the facility, the medications were not available for verification by the LPA. Staff interviews confirmed that the staff whom assisted R1 with the self-administration of medication always assisted R1. An interview with R1 confirmed no concerns regarding assistance with self-administration of medication. Based on the investigation, there is insufficient evidence to support the claim that the staff failed to assist resident with the self-administration of medication. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Staff failed to refill resident’s prescriptions in a timely manner It was alleged that Resident #1 (R1) has not had their prescriptions refilled in a month and a half. During a collateral visit to R1’s new residence on 7/27/2022 R1 communicated that they did not recall ever going without their medications or not having their medications refilled during their stay at Woodland Hills Retirement Home. Staff interviews confirmed that R1 was never without their prescriptions. During today’s visit, the LPA reviewed R1’s Centrally Stored Medication Log and found them to be in order, however the LPA was unable to confirm as R1 no longer resides at the facility. Staff denied that R1 ever missed a medication dosage. Based on the information obtained, there is insufficient evidence to support the claim that the facility did not properly manage R1’s medications. This allegation is deemed Unsubstantiated at this time. However, the LPA audited medications for 2 out of 3 residents and identified medication errors that were unrelated to this complaint and this will be addressed on a case management report. Exit interview conducted. No citations issued. A copy of report provided via email.the state’s words, verbatim · CDSS document, Sep 13, 2022 · control 29-NP-20220222171126

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Elsie Campos conducted an unannounced Case Management-Deficiencies inspection visit at the facility today due to deficiencies observed during the investigation of complaint control # 29-NP-20220222171126. At 11:45 a.m. the LPA conducted a medication audit. The LPA audited medications for two out of three residents. Resident #1 (R1), Resident #2 (R2) had prescription medications and PRN medications; however, medication documentation log was inaccurate. The LPA observed that on the medication notes, staff indicated inaccurately medication prescription RX numbers, medication expiration dates, and issued dates did not match with the medications on hand. The LPA had a discussion with the Administrator addressing the Centrally Stored Medication Log and its requirements to be current and updated anytime medication enters the facility. The facility plans to have a full medication audit completed by their local pharmacy within the next three weeks. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit (See 809-D). Exit interview conducted, today's reports and appeal rights were reviewed and issued via email.the state’s words, verbatim · CDSS document, Sep 13, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 15, 2022

87465(a)(4) Incidental Medical and Dental. The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on observation, the licensee did not comply in the section cited above for two out of three residents (R1, R2) which poses an immediate health and safety risk to residents in care. The Administrator agreed to the following:the state’s words, verbatim · CDSS document, Sep 13, 2022

Plan of correction: The Administrator agreed to do the following: 1. Schedule an in-service training with an outside agency within the next 48 hours and provide proof to CCL no later than 9/15/2022. 2. Host an in-service training with an outside agency around the self-administration of medications, specifically discussing all medication documentation and completing the Centrally Stored Medication and Destruction Record. Training and proof must be completed no later than 9/30/2022.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(h)(6) · Plan of correction due date: Sep 23, 2022

87465(h)(6) Incidental Medical and Dental Care: The following requirements shall apply to medications which are centrally stored: The licensee shall be responsible for assuring that a record of centrally stored presciption medications...is maintained… This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above, as two (2) out of three (3) resident files did not contain properly completed centrally stored medication logs, which poses a potential health, and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 13, 2022

Plan of correction: The Administrator agreed to do the following: 1. Host an in-service training with an outside agency around the self-administration of medications, specifically discussing all medication documentation and completing the Centrally Stored Medication and Destruction Record. 2. Update the Centrally Stored Medication Log for all residents and provide proof to CCL no later than 9/23/2022. Training and proof must be completed no later than 9/30/2022.

Allegation investigated: Facility is not meeting resident's need to have transportation arranged. Facility is not serving food of the quality or quantity to meet resident's needs. Facility is not meeting the requirements pertaining to fee increase for resident.

Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegations. The initial visit was conducted virtually on 2/01/2021 by LPA A. Richardson and a subsequent visit was conducted on 7/08/2022 by LPA M. Arroyo. On today’s visit, LPA Arroyo met with Administrator, Serguei Kalistrov. Entrance interview conducted. During the initial visit on 2/01/2021, LPA A. Richardson conducted a telephonic interview the Administrator at 3:00 p.m. and requested copies of resident records. During the subsequent visit on 7/08/2022, LPA M. Arroyo conducted a tour of the facility at 1:00 p.m. and conducted interviews with two staff and three residents. At 1:08 p.m., the LPA began record review of resident files and obtained copies of resident records and other pertinent documents relevant to the investigation. The LPA also interviewed family members on 7/13/2022 at 3:01 p.m., and on 7/22/2022 at 4:20 p.m. …Report Continued on LIC 9099C… Unsubstantiated …Report Continued from LIC 9099… It was alleged that facility is not meeting resident’s need to have transportation arranged. It was reported that R1 needed assistance from another person to accompany them to their doctor’s appointments. Record review of documents revealed that the facility had agreed to provide transportation to R1 to and from medical appointments. Per R1’s Admissions Agreement dated 07/01/2020, it states on page 4, “basic transportation to and from medical appointments is included within a radius of ten (10) miles on designated days…”. Additionally, R1 was being transported to their medical appointments being scheduled, but still required assistance beyond the transportation. Personal assistance to medical appointments was offered to R1’s responsible person under “Optional Service” for an additional monthly fee on page 3 of the Admissions Agreement which states, “personal escort to appointments”. However, this additional service was declined by R1’s responsible person upon admission to the facility on 07/01/2020. Based on the information obtained during the course of the investigation, the Department does not have sufficient evidence to support the allegation of “facility is not meeting resident’s need to have transportation arranged”. Therefore, the allegation is deemed Unsubstantiated at this time. It was also alleged that facility is not serving food of the quality or quantity to meet resident’s needs. It was reported that facility was only serving spaghetti and residents were not eating enough. During the visit on 07/08/2022, the LPA observed the kitchen and food supply. The facility had a variety of food including fruits, vegetables, milk, meats, eggs, and bread. Interviews with staff revealed that meals are cooked for the residents every day, and although the facility does not have menus, the residents have expressed no concern with the food served. Additionally, some residents have a favorite food that they prefer, which the staff will make for them more frequently. Family members stated no concerns with the quality of food and added that the staff has even tried many different ways to accommodate the residents to make sure they eat what they enjoy. Based on interviews and LPA observation, the Department does not have sufficient evidence to support the allegation of “facility is not serving food of the quality or quantity to meet resident's needs”. Therefore, the allegation is deemed Unsubstantiated at this time. It was further alleged that facility is not meeting the requirements pertaining to fee increase for resident. It was reported that R1 had only been at the facility for one month before receiving a notice that the rate fee would be increasing. Information obtained revealed that the Administrator of the facility had mailed out a letter indicating the facility’s monthly fee increase of $1,000. ...Report Continued on LIC 9099C... …Report Continued from LIC 9099… The letter mailed out to R1’s responsible person was dated 12/01/2020 and indicated the fee increase would be effective 02/01/2021. Additionally, the fee increase letter given to residents outlined specific reasons as to why the fee increase was primarily due. Furthermore, per R1’s Admissions Agreement, it was revealed that R1 was admitted to the facility on 07/01/2020, which was seven months before the expected fee increase was to take in effect. Interviews conducted revealed that the Administrator had given a two month notice to residents residing at the facility before 12/01/2020 regarding the $1,000 fee increase. Based on the information and documentation obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “facility is not meeting the requirements pertaining to fee increase for resident”. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted. No citations issued. A copy of report provided via email.the state’s words, verbatim · CDSS document, Aug 12, 2022 · control 29-AS-20210122100837

Allegation investigated: Staff failed to change resident's clothes Staff failed to reposition resident Staff failed to provide comfortable accommodations for the reside

Licensing Program Analyst (LPA) Elsie Campos conducted a subsequent complaint visit to this facility. The LPA met with staff Irina Fried and explained the reason for the visit. The Administrator Serguei Kalistratov was not present. During the initial visit conducted on 3/1/2022, LPA’s Elsie Campos and Ashley Smith interviewed a resident's responsible party at 2:44 p.m., interviewed residents at 1:45 p.m., and 1:59 p.m., and, interviewed staff at 3:12 p.m., 3:27 p.m. and 3:46 p.m. The LPA's also obtained documents pertinent to the investigation. During today’s visit the LPA, interviewed staff at 3:10 p.m. and 3:18 p.m., interviewed residents at 3:30 p.m., 3:40 p.m. and 4:15 p.m. and obtained additional documents at 4:28 p.m. Unsubstantiated Regarding the allegation: Staff failed to change resident’s clothes It was alleged that staff, are not changing the resident’s clothes. Interview with Resident #1 (R1) revealed that they would be left in the same clothes for extended periods of time, but R1 did not specify the time frame. Information obtained from interviews with responsible parties who had been in the facility, claimed that R1 was observed to be in the same clothes when they would visit but could not confirm if it was clean or not. During the 3/1/2022 visit, R1 was in the process of moving and appeared to be in clean clothes. Further interviews claimed that residents are being changed daily. Staff #2 (S2) stated that Resident #2 (R2) refuses to wear additional clothes but sometimes is unable to persuade R1 to wear something different. During today’s visit residents appeared well groomed and in clean clothes. Based on interviews which were conducted, there is insufficient evidence to support the allegation that staff failed to change the resident’s clothes. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated at this time. Regarding the allegation: Staff failed to reposition resident It was alleged that resident is not being turned regularly. Interviews with staff revealed that facility staff reposition residents that require repositioning as needed and every two hours. Interviews with staff revealed that all facility staff are trained in repositioning. Interviews with facility staff revealed that staff were able to move/reposition R1 who required to be taken to the bathroom for showers and occasional toileting. Interviews with residents confirmed that staff are repositioning them as needed and every two hours. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time. Regarding the allegation: Staff failed to provide comfortable accommodations for the resident It was alleged that staff, failed to provide comfortable accommodations for the resident. The complainant alleged that R1 reported that a space heater was left in their room making it extremely hot. Interviews with R1 denied allegations that a space heater was ever left however an overhead central heating system would occasionally be turned on by a senile resident. R1 confirmed that if the temperature would get uncomfortable that staff would adjust it. Further interviews confirmed that facility temperature is comfortable and remains comfortable throughout the day and night. During today's complaint visit, the LPA observed the facility to have the thermostat set a comfortable temperature of 75 degrees Fahrenheit. Based on the investigation, there is insufficient evidence to support the claim that staff failed to provide comfortable accommodations for the resident. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Staff fell asleep in resident’s room It was alleged that staff fell asleep in the resident’s room while on shift. Interview with Resident #1 (R1) revealed that Staff #1 (S1) had fallen asleep more than once in their room on a couch located in the room, while conducting routine care checks. Information obtained from interviews with responsible parties who had been in the facility, confirmed claims that staff were observed sleeping in common spaces. S1 confirmed that they sleep at the facility on a couch in the living room or rests in the daytime on a bed outside. Additional staff interviews confirmed that staff do sleep in the living room couch during the night shift. During the 3/1/2022 visit, the LPA’s did not observe a designated staff room. The LPA discussed personal accommodations relating to staff and residents with Staff Irina Fried. Based on the investigation, there is sufficient evidence to support the claim that staff fell asleep in resident’s room. This allegation is deemed Substantiated at this time. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit (See 9099-D). Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 3, 2022 · control 29-NP-20220222171126

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(B) · Plan of correction due date: Aug 10, 2022

87307(a)(B) Personal Accommodations and Services Living accommodations... shall ... provide...privacy for the residents, staff...(B) No room commonly used for other purposes shall be used as a sleeping room...This requirement is not met as evidenced by: Based on observation, the licensee failed to ensure that common areas were used appropriately, as staff confirmed sleeping on the couch, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 3, 2022

Plan of correction: The Administrator has agreed to do the following: 1. Submit a statement to CCL, stating the appropriate use for common rooms and how they will be utilized. Submit Statement of Understanding by 8/10/22.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced to conduct a required annual visit. This annual had a specific emphasis on infection control practices and procedures. The LPA met with staff and explained the reason for the visit. The Administrator Serguei Kalistratov arrived shortly thereafter. The LPA, with the guidance of staff, 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. BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There are six bedrooms for resident use. RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. During the visit, the LPA did not observe signage 2 out of 3 bathrooms pertaining to proper hand hygiene. In addition, restroom hot water measured between 115.8 and 138.2 degrees Fahrenheit between 10:32 a.m. and 10:42 a.m. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. All exits have functioning auditory devices. Smoke detectors are hardwired and interconnected and tested at 11:15 a.m. The fire extinguisher was observed to be full and last bought on 5/26/21. The LPA observed cameras in all common spaces and a screened fireplace in the living room. The LPA did not observe all the required postings in the common area. Amongst the missing postings were the department provider information notices (PIN) and department let me know poster. The administrator was reminded of the department’s guidelines regarding postings and signage. In addition, at 10:36 a.m., the LPA observed accessible personal hygiene, over the counter medications and prescription medications in the hallway closet, belonging to staff. These items were properly secured at the time of the visit. BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. At 10:57 a.m., the LPA observed the door to the water heater to be in disrepair, and advised the administrator to ensure it is repaired and secured. KITCHEN: The LPA observed the Kitchen dishwasher to be inoperable, and per the administrator is not used. The administrator was advised that all kitchen appliances need to be in good repair and operable. The facility has a sufficient supply of perishable food and nonperishable food; however, the LPA observed expired hot dog buns, expired milk, and moldy cauliflower in the kitchen between 10:46 a.m. and 10:49 a.m. These items were disposed of at the time of observation. At 10:45 a.m., the LPA observed accessible cleaning supplies under the kitchen sink. At 10:33 a.m. the LPA observed unlocked medications in the clear medication cabinet. These items were properly secured at the time of the visit. At 10:44 a.m. the LPA observed unlocked kitchen knife cabinet, which was locked at the time of observation. At 10:52 a.m. the LPA observed an unlocked door leading to the garage and laundry area containing laundry detergent, disinfectants, and other chemicals. At 10:54 a.m. the LPA observed a kitchen cabinet with unsecured scissors which were properly secured at the time of the visit. Kitchen hot water measured 113.3 degrees Fahrenheit at 11:03 a.m. INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time and the LPA reviewed facility’s policies and procedures as it pertains to infection control. The administrator was also advised that all staff need to be cleared before entering the facility. The following recommendations were made: - Appropriate signage to remind staff and residents of hand washing hygiene, visitation policies and procedures etc. - Posting Provider Information Notices (PINs) and educating staff, residents, and families on changing policies and procedures from the Department. In addition to obtaining and displaying the departments Let Me Know poster. -Continue Screening visitors and Staff and ensure visitors and staff continue following masking guidelines. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided via email.the state’s words, verbatim · CDSS document, Apr 19, 2022

The state marks this report as 13 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Allegation investigated: Resident sustained several pressure injuries while in care

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint visit on 03/24/2022 to deliver findings for the above allegation. The initial visit was conducted on 05/26/2020 by LPA Aja Richardson telephonically via a video chat and a subsequent visit was conducted on 03/15/2022 by LPA Camara. During today’s visit, the LPA met with the facility administrator, Serguei Kalistratov and explained the reason for the visit. On 05/22/2020, the Department received a complaint regarding the allegation Resident #1 (R1) sustained multiple pressure injuries while in care. Some of these pressure injuries were first noted by Medical Center staff upon initial exam on 05/20/2020. (continued on 9099-C) Unsubstantiated On 05/26/2020, between 2:45 p.m. and 3:15 p.m., LPA Richardson conducted the initial complaint visit. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint investigation was conducted telephonically. At 2:45 p.m., the LPA conducted an interview and physical plant tour via video call with facility administrator Serguei Kalistratov. At 3:00 p.m., the LPA requested copies of pertinent documents relevant to the investigation and noted further investigation would be required. On 05/26/2020, LPA Richardson ordered the following records: - home health records from R1’s Home Health Agency - medical records from the hospital for R1’s admission on 05/14/2020 - medical records from the Medical Center for R1’s admission on 5/20/2020 On 10/17/2020, LPA Richardson conducted telephonic interviews with the administrator at 10:00 a.m. and R1’s responsible party (RP) at 1:00 p.m. The RP indicated R1 was originally admitted to the facility with wounds and received wound care from the home health agency. The RP had concerns about facility staff not repositioning R1 frequently enough or providing incontinence care at night because the night shift staff slept at the facility. The RP stated that after R1’s stay at the hospital on 05/14/2020 through 05/18/2020, R1 returned to the facility in worse condition. The RP stated R1 was admitted to the Medical Center for further care on 05/20/2020. The RP was aware R1 had developed more pressure injuries but could not say if they developed at one of the hospitals or the facility. The administrator stated R1 was released from the Medical Center on 05/26/2020 on hospice and R1 passed away on 06/04/2020. During LPA Camara’s visit to the facility on 03/15/2022 between 12:15 p.m. and 1:27 p.m., LPA Camara interviewed a visitor at the facility at 12:17 p.m., conducted a brief plant tour at 12:26 p.m., and interviewed the administrator at 12:45 p.m. The administrator stated he was the primary caregiver for R1; he ensured he and the staff kept R1 clean and repositioned as per the home health nurse directions. Due to the age of R1’s records, they were no longer stored at the facility. The administrator was asked to bring R1’s records, including hospice records, to the Community Care Licensing (CCL) office in Woodland Hills the following day. On 03/16/2022, the administrator came to the CCL office with R1’s records, however the administrator did not (continued on 9099-C) have any hospice records for R1. The administrator stated he recalled the home health agency provided the hospice services. On 03/22/2022, LPA Camara contacted the home health agency to obtain information about hospice care services. LPA was informed that the agency only provides home health services, they are not a hospice agency. They already provided all of the records they have for R1. Information gathered reflected R1 was initially admitted to the facility on 05/01/2020 from a skilled nursing facility. R1 was evaluated by home health on 05/02/2020 and it was noted R1 had a skin tear on the right lateral arm and two Stage 2 pressure injuries: one on R1’s coccyx and one on R1’s left heel. R1 received wound care from the home health agency on the following dates: 05/02/2020, 05/05/2020, 05/08/2020, 05/11/2020, and 05/14/2020. On the evening of 05/14/2020, facility staff called 9-1-1 for R1 due to R1’s altered mental state. R1 was admitted to the hospital and was diagnosed with sepsis and unstable angina. R1 was released from the hospital on 05/18/2020 with a recommendation to consider hospice. There was no mention of the state of R1’s wounds/skin in the hospital records upon R1’s release and the facility administrator did not complete a reappraisal. On 05/20/2020, R1 was experiencing confusion and dehydration due to diarrhea. R1 was sent to the Medical Center and admitted. The Medical Center noted several pressure injuries/redness: coccyx, left heel, right hip, right lateral back, right lateral foot, right lateral ankle, redness on groin, and penial swelling. (Note: The Medical Center did not note the stage of the wounds.) R1 was released from the Medical Center on 05/26/2020 with instructions to contact hospice within 24 hours. The administrator did not complete a reappraisal, nor did the administrator have any information regarding which hospice agency provided services to R1. Based on the home health and hospital records, it was unclear where R1’s new pressure injuries occurred since R1 had just recently been released from a hospital inpatient stay and it was unclear if the two original wounds on the coccyx and left heel had advanced beyond Stage 2. In addition, R1 was under the care of home health prior to R1’s two hospital stays. There was no indication in home health records of the wounds worsening or that facility staff were not following their directions. As a result, there is insufficient evidence to confirm that R1 developed pressure injuries due to facility staff neglect; therefore, this allegation is deemed Unsubstantiated at this time. Exit interview conducted and a copy of the report issued.the state’s words, verbatim · CDSS document, Mar 24, 2022 · control 29-AS-20200522094856

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Teresa Camara conducted an unannounced Case Management – Deficiencies visit on 03/24/2022, in conjunction with complaint control # 29-AS-20200522094856. LPA met with facility administrator Serguei Kalistratov and explained the reason for the visit. During the course of the investigation of the above noted complaint, it was discovered the administrator failed to do the following: -obtain a hospice care plan for Resident #1 (R1) or retain any hospice records -report R1 entering into hospice to Community Care Licensing (CCL) -complete a reappraisal for R1 after R1’s hospital stays and change in condition -report two incidents when R1 was admitted to the hospital. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted, today's reports and appeal rights were reviewed and issued to administrator at serguei35@yahoo.comthe state’s words, verbatim · CDSS document, Mar 24, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87632Id)(2) · Plan of correction due date: Apr 1, 2022

87632 Hospice Care Waiver (d) If the Department grants a hospice care waiver it shall stipulate terms and conditions of the waiver as necessary to ensure the well-being of terminally ill residents and of all other facility residents, which shall include, but not be limited to, the following requirements: (2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date ofthe state’s words, verbatim · CDSS document, Mar 24, 2022

Plan of correction: Administrator will submit a written plan for reporting to CCL any residents who enter into hospice. This will be provided to CCL by 04/01/2022. admission to the facility and the name and address of the hospice. This requirement was not met as evidenced by: No record of licensee reporting R1's entry into hospice to CCL was found, which posed a potential health and safety risk to residents.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87633(h) · Plan of correction due date: Apr 1, 2022

87633 Hospice Care of Terminally Ill Residents (h) For each terminally ill resident receiving hospice services in the facility, the licensee shall maintain the following in the resident’s record: (4) A copy of the resident’s current hospice care plan approved by the licensee, the hospice agency, and the resident, or the resident’s Health Care Surrogate Decision Maker if the resident is incapacitated. This requirement was not met as evidenced by: Licensee had no records regarding R1's hospice care, including no hospice care plan or hospice care provider visits, which posed a potenital health and safety risk to residents.the state’s words, verbatim · CDSS document, Mar 24, 2022

Plan of correction: Administrator will submit a written plan for obtaining and retaining hospice care plans and hospice records. This will be provided to CCL by 04/01/2022.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Apr 1, 2022

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such asthe state’s words, verbatim · CDSS document, Mar 24, 2022

Plan of correction: Administrator will submit a written plan for reporting unusual incidents to CCL. This will be provided to CCL by 04/01/2022. psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidenced by: Licensee failed to report two incidents of R1 requiring hospitalization, which posed a potential health and safety risk to residents.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(a) · Plan of correction due date: Apr 1, 2022

87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. This requirement was not met as evidenced by: After R1's two inpatient hospitalizations in which hospice was advised due to R1's declining health, licensee failed to complete a reappraisal of R1's condition, which posed a potential health and safety risk to residents.the state’s words, verbatim · CDSS document, Mar 24, 2022

Plan of correction: Administrator will submit a written plan for conducting reappraisals of residents when residents have a change in condition. This will be provided to CCL by 04/01/2022.