Ocean Breeze Care Home II

Type of visit: Required - 1 Year

On 2/16/23 Licensing Program Analyst Alfonso Iniguez conducted an unannounced visit to this facility. The purpose of today’s visit was to conduct an Annual inspection. LPA met with Gregg MacEllven/Owner-Administrator. Facility is licensed for (6) non-ambulatory residents. The facility has an approved hospice waiver for (2) residents. The facility currently has (5) non-ambulatory residents, who are residing in the facility. The facility does not handle residents’ cash resources. LPA toured the facility. The facility consists of (6) resident bedrooms, (3) bathrooms, living room, dining room and kitchen. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Bathrooms are clean, sanitary, and fixtures are working properly, the bathrooms grab bars are secure and non-skid mats in place. The facility water temperature properly measured at 111 F°. Resident bath towels, toiletries, and personal hygiene supplies were adequately stocked. Common areas were clean and hazard free. All doorways were free of obstructions and have auditory alarm. The kitchen is clean, sanitary, and observed to be within Title 22 regulations. The facility currently has a sufficient supply of perishable as well non-perishable food items. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors and Carbon monoxide detectors were tested and found to be operating properly. Outside grounds were toured and no bodies of water were observed. All walkways around the home were clear of hazards. The front porch and the back patio have shaded and sitting areas for residents and visitors. LPA observed a sign-in/sanitation station at the facility entry. There is hand sanitizer and masks available in the facility. Facility has screening process for all visitors, sanitizer/soap, paper towels, and additional PPE supplies are stored inside the facility and garage. The facility is prepared to provide a private room for isolation if needed. The facility mitigation plan was approved by CCL on 5/23/2021. A copy of the liability insurance was provided to LPA. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to the Owner/Administrator Gregg McEllven .the state’s words, verbatim · CDSS document, Feb 16, 2023

Allegation investigated: Resident sustained injuries while in care. Resident sustained multiple falls while at the facility due to lack of supervision by staff. Facility staff failed to meet the resident's needs.

Licensing Program Analyst (LPA) Ana Soto made an unannounced visit to the facility and was greeted by Administrator Gregg MacElluen. The purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations. Licensing Program Manager (LPM) Janae Hammond initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Gregg MaCelluen, the facility administrator. LPM Hammond conducted telephone interviews with the administrator and a video call - which consisted of a review of food supply, physical plant, medication area, and reviewed Resident #1's records (Emergency ID Sheet, Physician’s Report, Admission Agreement, Needs & Service Plan, Physician’s Orders (for postural supports), Staff Training Logs (for 6 months). Substantiated Regarding Allegation #1: this investigation revealed that Resident #1 was transported to Providence Little Company of Mary Medical Center on 03/23/20 with a right thumb fracture, blunt head trauma, chronic anti-coagulation, and dementia. Resident #1 also had a large amount of soft tissue swelling on the left side of her head, but scans showed no evidence of an acute skull fracture or brain bleed. The two caregivers S1- S2 that were present during the fall both presented contradictory statements and were inconsistent in their interviews. Staff #1 claimed she was in the hallway when Resident #1 fell. Staff #1 stated that Staff #2 pushed and guided Resident #1 through the bedroom door towards the restroom – which was approximately 15 feet away from Resident #1’s bedroom. Both caregivers entered the bathroom with Resident #1 when she slid out of her wheelchair and hit her head on the floor. Staff #1 was in the bathroom facing away from Resident #1 and Staff #2. Staff #1 stated that she did not see the fall; but, she heard a loud bang noise and believed it was due to Resident #1 hitting her head on the hard floor after the fall from her chair. Staff #2 claimed that Resident #1 had a bowel movement in bed and needed to be transported to the bathroom to be cleaned. Resident #1 was placed on a transport wheelchair then led to the bathroom with one caregiver in front and another behind Resident #1. Staff #2 claimed Staff #2 initially stated they were right next to the bathroom door when Resident #1 fell very quickly from her transport wheelchair. Resident #1 slid forward off the transport wheelchair and bumped her head on the bathroom door jamb. Upon a follow-up interview with Staff #2 , she stated that she had observed Resident #1 hit her head on the hallway floor. After the fall, Staff #2 stated that Resident #1 sat on the hallway floor in a daze. Staff #2 noticed a bump on Resident #1’s head immediately. Staff #2 stated that she put ice on Resident #1’s head injury and called 911 immediately. Staff #2’s narrative did not coincide with the narrative given by Asst. Administrator. Staff #2 stated she called 911 immediately, while Asst. Administrator claimed that she put ice on Resident #1’s head injury and called 911 immediately. Review of Resident #1 records revealed Resident was a fall risk. Staff #2’s inconsistent interview responses and both witness’ contradictory statements placed doubt on how well Resident #1 was being supervised before the fall and how well Resident #1 was being taken care of while being transferred to the bathroom. Based on evidence gathered and interviews conducted and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF CARE: Resident sustained injuries while in care is found to be SUBSTANTIATED. Regarding Allegation #2: When Resident #1 arrived to the facility on 02/21/20, the facility provided a queen-size bed; and, staff were told that this was dangerous because Resident #1 was a fall risk. The very first day 02/21/2022, Resident #1 was lying in bed and during the night fell onto the ground. Administrator stated that Resident #1 had rolled off the bed onto some pillows that were placed on the ground near the bed. Although, Resident #1 may have landed onto the pillows, the resident sustained a bump on her head. Facility did not agree initially to a hospital bed for Resident #1, but eventually provided a hospital bed (w/ half rails) that arrived one (1) week later. Witness #3 mentioned that Resident #1 fell multiple times during the day; but, could not recall exactly how many times or dates that Resident #1 had fallen at the facility. Witness #3 claimed that while facility staff transported residents to the restroom and out of their wheelchair, observed that facility staff were often extremely forceful and rough. Witness #3 observed no uniformity or standard operating procedure from facility staff when residents were being transported. Although, Asst. Administrator indicated that facility was unaware of Resident #1 being a fall risk. A review of Resident #1’s “Physician’s Report” (dated 11/15/19) under “Capacity for Self Care” documents Resident #1 cannot ambulate without assistance. “Resident Appraisal” (dated 02/19/20) under “Functional Capabilities” documents Resident #1 needs assistance with walker and wheelchair. A physician’s order (dated 03/02/20) documents a “Semi-electric hospital bed with ½ rails” was still current and prescribed by her physician. Based on evidence gathered and interviews conducted and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF CARE: Resident sustained multiple falls while at the facility due to lack of care/supervision by staff is found to be SUBSTANTIATED. Regarding Allegation #4: this investigation revealed that Witness #2 noticed during visits to the facility, staff provided poor care and were poorly trained. Resident #1 developed a diaper rash while living at the facility; of which, Resident #1 never had skin issues before she arrived at the facility and due to the infrequent diaper changes, it led to her diaper rash. Witness #2 claimed hospice supplies were delivered and signed for, but were not able to be located - including a wheelchair that was provided for Resident #1 was nowhere to be found at the facility. Administrator and Asst. Administrator had no explanation for the missing supplies and equipment (wheelchair) or the hospital bed (w/rails) that was delivered a week late. Based on evidence gathered and interviews conducted and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF CARE: Facility staff failed to meet the resident’s needs is found to be SUBSTANTIATED. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency was observed and a citation issued (ref. LIC 9099D). At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.” Civil Penalties Assessed. An exit interview was conducted and a copy of the Complaint Report and Appeal Rights were provided to Administrator Regarding Allegation #3: this investigation revealed that the medical professionals did not suspect abuse and attributed the physical injuries from the witnessed fall that Resident #1 sustained. All facility caregivers and administrators denied Resident #1 was ever physically abused or physically restrained while in care at the facility. Majority interviews conducted expressed how they enjoyed the care and services they received at the facility; and, they did not observe physical abuse or residents being restrained. Witnesses interviewed did not suspect physical abuse nor residents being restrained during their visits to the facility. Based on the evidence gathered and interviews conducted and records reviewed, the allegation may have happened or is valid; however, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of PHYSICAL ABUSE: Facility staff restrained resident is found to be UNSUBSTANTIATED. An exit interview was conducted and a copy of the Complaint Report was provided to Administrator.the state’s words, verbatim · CDSS document, Mar 11, 2022 · control 11-AS-20200403131604

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(4) · Plan of correction due date: Mar 28, 2022

87705(c)(4): Care of Persons with Dementia. (c) Licensee who accept and retain residents with dementia shall be responsible for ensure the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety, and health care needs as identified in his/her current appraisal. This requirement is not met as evidence by: Based on interviews conducted and records reviewed the Licensee failed to ensure Residents #1 needs were met resulting in the resident sustaining serious bodily injuries. This poses a health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 11, 2022

Plan of correction: Administrator shall provide training to resident in care for persons with Dementia. The Administrator shall provide a copy of the training materials and sign-in sheet and submit to CCL by POC due date. A $500 immediate civil penalty was assessed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Mar 28, 2022

87466: Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional, and social functioning, and that appropriate assistance is provided when such observation reveals unmet needs.......... Based on interviews and records reviewed the licensee failed to ensure after repeated falls R1 was reassessed. This poses an health & safety risk to resident in care,the state’s words, verbatim · CDSS document, Mar 11, 2022

Plan of correction: Administrator shall provide staff with training on observation of the residents. Administrator will provide copies of training materials and sign in sheet to CCL by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1)(2) · Plan of correction due date: Mar 28, 2022

87468.1(a)(1)(2): Personal Rights of Residents in all Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: ....... Based on interviews and records review the licensee failed to ensure R1 belongings were properly safeguarded. This poses a personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 11, 2022

Plan of correction: Administrator shall ensure residents belongings are properly stored and secured. Administrator shall train stall in residents Personal Rights. Administrator shall provide training materials and sign in sheet to CCL by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ana Soto conducted an unannounced Annual required and infection control visit to the above facility. LPA was met by Gregg MacElluen, administrator and the purpose of today’s visit was explained. There are currently (4) residents in the facility. (4) residents are ambulatory and (0) are non-ambulatory. The facility is a single story structure located in a residential neighborhood. It consists (6) bedrooms, (3) full bathrooms - 2 for residents and 1 for staff, shaded back yard, front yard, laundry room and attached 2 car garage. LPA and Gregg toured the entire facility inside and out. Documents are posted as mandated. Bedrooms 1-4 are occupied by residents and contain the mandated furniture. Bedroom 5 & 6 vacant but contain the mandated furniture. The (2) bathrooms are clean and operational. First aid kit is fully stocked with manual, smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and there's a water fountain in the back yard does not pose a hazard to residents. Medications are stored, locked and inaccessible to residents. Residents Medications and file are current. Staff file is current. Ample supply of perishable and nonperishable food, hot water temperature is 114 degrees Fahrenheit, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents, 1 fire extinguisher is fully charged. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in good repair. During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry, visitors are logged and temperature checked, sanitizer/soap in the bathrooms and additional sanitation supplies are locked in the garage. LPA observed staff and residents wearing masks, resident private rooms will be converted to isolation rooms (if needed) and required postings throughout the facility. The residents temperature's are checked and logged once a day. PPE's are enough for 30 days. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time. An exit interview conducted with Gregg MacElluen, Administrator and copy of report provided.the state’s words, verbatim · CDSS document, Feb 17, 2022

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.