Primecare Bellflower

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Caregivers, Jeneffer Reyes and Jesusa Sargento and explained the purpose of the visit. At 1:52pm, Administrator, Hiransha Keerthisinghe arrived and assisted LPA with the inspection. There are six (6) residents of which three (3) are in hospice care residing in the home. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and the following was inspected during the evaluation: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor screening station at the entrance of the facility. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan and was reviewed. Facility has COVID-19 signage posted in the facility. Common area surfaces are being cleaned and disinfected on a regular basis. Bathrooms have liquid soap and paper towels. Staff are adhering to infection control requirements. Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. A fire clearance is in place. Liability Insurance policy in the amount of $1,000,000.00 each occurrence and #3,000,000.00 in the total annual aggregate is valid and will expire on 2/18/2024. The last fire Drill was conducted on 5/25/2023. Care and supervision to meet the residents needs was observed. Special equipment and supplies to meet the persons with special needs were observed. Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood that is licensed for age range 60 and over, approved for one (1) ambulatory and five (5) non ambulatory, of which 1 may be bedridden. Non ambulatory in bedrooms 2, 3 & 4, bedridden in room #4. Facility has hospice waiver for 2. In July 2022, an approved hospice waiver for four (4) residents was granted. Facility consists of four (4) resident bedrooms, three (3) bathrooms, living room, office area, dining room, kitchen, backyard, patio area, and an attached garage. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors are operational. The facility has (1) fully charged fire extinguisher located in the living room. Fire extinguisher was last inspected on 7/11/2023. Cleaning supplies and toxic substances are inaccessible to clients. Hot water temperature readings measured 109.2 deg F in bathroom #1, 109.7 in bathroom #2 and 110.8 deg F in bathroom #3 which are within the required 105-120 degrees Fahrenheit. ***CONTINUED ON LIC 809-C*** Staffing: A total of seven (7) caregivers including the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have the required training and associated to the facility. Personnel Records-Training: Administrator certificate is valid and expires on 5/12/2024. Two (2) staff files were reviewed for criminal background clearance and training. Personnel records have health/TB screenings. One (1) staff has expired First Aid/CPR training. Resident Records-Incident Reports: Three (3) resident files were reviewed containing admission agreements, Physician's Report, Medical/Functional assessments, Needs and Services Plans, TB clearance, Personal rights, Medical Consent, Medication Records, Restricted Health Care Plans and Hospice Records were reviewed. Resident Rights-Information: Resident personal rights are posted. Physician orders for use of full/half bed rails were reviewed in residents files. LPA conducted (3) resident interviews. Planned Activities: Information regarding Dementia is part of training for direct care staff and is included in the Plan of Operation. Food Service: The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. The food is properly stored in the refrigerator (clean and well maintained). Two (2) residents have a special soft diet residing at this facility. Pesticides and cleaning supplies are kept away from the food preparation areas. Plates, cups and utensils are kept cleaned and stored properly. Incident Medical and Dental: All residents have Restricted Health Care Plan and Needs and Services Plan on file. Home Health personnel services the residents in the facility. Hospice and Home Health Nurses administer suppositories to the residents. Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan containing emergency evacuation, storage and preservation of medications, operation of manual assist devices. The facility conducts emergency drill on a quarterly basis for all staff and residents. Per California Code of Regulations, Title 22, deficiencies were cited. Exit interview conducted with Administrator Hiransha Keerthisinghe. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Jul 31, 2023

Allegation investigated: Resident sustained a subdural hematoma while in care Facility staff did not seek medical attention in a timely manner

Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegation(s). LPA Flores met with Jocelyn Moon Caregiver and explained the reason for the visit. Hiransha Keerthisinghe administrator arrived 15 minutes later. The investigation consisted of the following: On 7/14/21 LPA Flores conducted a Health and Safety Check tour with facility's administrator Hiransha Keerthisinghe. In the kitchen, LPA observed sharp utensils were kept on drawer next to stove and cleaning supplies kept in cabinet under sink. Both have locks but do not lock properly. LPA Flores reviewed Resident # 1 (R1), Resident #2 (R2), Resident #3 (R3), Resident 4 (R4), and Resident #5 (R5) records. LPA also reviewed R1’s, R2’s, and R5’s medication. The following documents were requested from R1’s file: Physician report, admission agreement, and medication sheets. On 12/9/21 Investigator with Investigation Bureau (IB), Loraine Patterson conducted interview with administrator. On 5/20/22 a referral to the Department's clinical consult program was submitted. (CONTINUED ON LIC 9099C) Substantiated The investigation revealed the following: Regarding allegation: Resident sustained a subdural hematoma while in care. It is alleged R1 was sitting in a wheelchair, being spoon fed dinner, and had a "very large hematoma" on the left side of R1's forehead. Per admission agreement, R1 was admitted to the facility on 6/26/21. Upon arrival administrator noted R1 was missing a medication. On 6/29/21 R1's responsible party was notified that R1 had "knocked head on the wall" over the phone around 9:00am. At around 5:30pm R1's responsible party arrived at the facility and took R1 to College Medical Center for medical care. R1 had a diagnosis of Dementia per physician's report dated 6/14/21. Medical records note that on 6/29/22 at 8:20pm, R1 was admitted to College Medical Center with chief complaint as suicidal ideation and unwitnessed abrasion to the forehead. A transfer from College Medical Center to St. Mary's Medical Center was arranged for R1 on 6/29/21 for higher level of care due to blunt head injury. R1 was admitted at St. Mary's Medical Center on 6/30/21 at 00:57am due to subdural hematoma. R1 went through two (2) procedures to assist with hematoma between 6/30/21 and 7/1/21. On 7/10/21 R1 was placed on hospice care due to R1's status. On 7/14/21 R1 passed away at the hospital. Death report revealed cause of the death was due to blunt head trauma. Administrator was interviewed and stated to have observed a "tiny redness approximately 1/2 inch on the left side of forehead." Per administrator R1 had restless behaviors for 3 days, such as lack of sleep and statements of wanting to "kill self". Based on interviews and observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Tittle 22, Division 6 and Chapter 8 are being cited. Regarding allegation: Facility staff did not seek medical attention in a timely manner. It is alleged on the morning of 06/29/2021, the responsible party received a telephone call from the facility advising that the facility was going to call 911, but facility never called 911 and the resident was not transported to the hospital. On 6/29/21 at approximately 9:00am, R1's responsible party was notified that R1 had "knocked head on the wall". At approximately 5:30pm, R1's responsible party arrived at the facility and took R1 to College Medical Center for medical care. Medical records note that on 6/29/22 at 8:20pm R1 was admitted to College Medical Center with chief complaint as suicidal ideation and unwitnessed abrasion to the forehead. A transfer from College Medical Center to St. Mary's Medical Center was arrange for R1 on 6/29/21 for higher level of care due to blunt head injury. (CONTINUED ON LIC 9099C) R1 was admitted at St. Mary's Medical Center on 6/30/21 at 00:57am due to subdural hematoma. On 7/10/21, R1 was placed on hospice. On 7/14/21; R1 passed away at the hospital. Death report revealed cause of the death was due to blunt head trauma. Interview with administrator revealed, administrator contacted R1's responsible party in the morning and upon responsible party arriving they requested they will drive R1 to the hospital and administrator "should have called 911" instead. Based on interviews and review of documentation regarding R1, the preponderance of evidence standard has been met, therefore, the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D. ***An immediate Civil Penalty of $500.00 is being issued today, due to resident sustained a subdural hematoma while in care. Refer to LIC 421IM*** The issuance of a civil penalty is being considered based on Health & Safety Code 1569.49(e) - (f); if the department determines the death of the client is due to neglect.the state’s words, verbatim · CDSS document, Mar 16, 2023 · control 28-AS-20210713104812

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Mar 17, 2023

87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities shall...:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidence by: Based on documents review, and interviews Licensee failed to ensure R1 did not sustained a subdural hematoma to the head which poses an immediate health, safety, or personal rights risk to the persons in care.the state’s words, verbatim · CDSS document, Mar 16, 2023

Plan of correction: Administrator and licensee will obtain training from an outside source in procedures to ensure the safety of the resident and emergency situations, contacting 911,and will provide training to staff regarding injuries and contacting 911. Administrator will schedule training by POC due date 3/17/23 and submit training to the dept. by 3/23/23.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Mar 17, 2023

87465 Incidental Medical and Dental Care: (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis... This requirement is not met as evidence by: Based on documents review, and interviews conducted Licensee failed to contact 911 in a timely manner which poses an immediate health, safety, or personal rights risk to the persons in care.the state’s words, verbatim · CDSS document, Mar 16, 2023

Plan of correction: Administrator and licensee will obtain training from an outside source in procedures to ensure the safety of the resident and emergency situations, contacting 911,and will provide training to staff regarding injuries and contacting 911. Administrator will schedule training by POC due date 3/17/23 and submit training to the dept. by 3/23/23.

Type of visit: Required - 1 Year

On 7/12/22 at 11:33 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced visit for the purpose of conducting the required annual inspection. On today's visit LPA met with Administrator, Hiransha Keerthisinghe who assisted with the visit. The facility is licensed to serve 6 residents, 60 and older. The facility is approved for 1 ambulatory and 5 non ambulatory, of which 1 may be bedridden. Non- ambulatory in bedrooms 2,3,4. Bedridden in bedroom 4. Hospice waiver for 2. Facility cares for dementia residents and has delayed egress on exit doors. The facility is a single-story building in a residential area, with a commercial kitchen, dining room, living room, 4 bedrooms, 3-bathroom, backyard with ample shaded area and a garage. Fire extinguisher observed in dining room fully charged. There are smoke detectors/ Carbon monoxide located throughout the facility, tested and operational. LPAs discussed infection control practices with administrator, toured the facility inside and out, reviewed food supply, reviewed staff files, and reviewed resident medications. Report continued on 809c Bedrooms have the required furniture including bedframes, dressers, lamps, and chairs. Beds have the required linen and the linen is in good condition. Passageways and exits are free of obstruction. LPA toured the kitchen and observed 7 days of perishables and 2 days nonperishable. The front and backyard are well maintained. The resident bathrooms are clean, and showers have non-skid materials and grab bars. The hot water temperature measured at 109.3- 111.4 degrees F. The facility temperature at the time the visit was comfortable. There is sufficient lighting throughout the facility. LPA observed a sufficient supply of PPE in the garage. Infection control signs were observed throughout the facility. Medications reviewed for all residents and appears to be given as prescribed. Facility file reviewed revealed administrator certificate # 6039969740 expire 5/12/2024. Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided to Administrator.the state’s words, verbatim · CDSS document, Jul 12, 2022

Allegation investigated: Facility did not provide a copy of the resident's records to the resident's representative in a timely manner.

Licensing Program Analyst (LPA) Galarza conducted an initial complaint visit to investigate the above allegation.The purpose of the visit was discussed with caregiver staff Lorna Montemayor. Administrator Hiransha Keerthisinghe arrived shortly after. The investigation consisted of the following: A tour of the interior and exterior physical plant was conducted. Residents (R2- R4), Licensee/Administrator staff (S1), and staff (S2-S3) were interviewed. Resident (R1) was discharged from facility on July 9, 2021 and was not interviewed. An interview was attempted with cognitively impaired resident. Resident (R1's) file documents were obtained [Physician Report, Preplacement Appraisal, Admission Agreement, Physician Order Sheet, Medication Administration Record (MAR), Administrator Log notes, discharge notice, incident report, resident roster, and LIC 500 Personnel Report. See LIC 9099C for report continuation. Substantiated Allegation: "Facility did not provide a copy of the resident's records to the resident's representative in a timely manner." Based on records review the findings indicate that on September 13, 2021 licensee received a letter requesting resident (R1's) file record documents. Per staff interviews, resident (R1) lived at the facility from June 26, 2021 - June 29, 2021. The resident was discharged on July 9, 2021 and passed away on July 14, 2021. Administrator stated that resident (R1's) records were sent via Overnight Express on September 17, 2021. Per California Health and Safety Code section 1569.269(a)(21) resident and or responsible party shall "have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided, not to exceed two business days, at a cost not to exceed the community standard for photocopies." Based on document review and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are being cited according to Title 22, Division 6 Health and Safety Code. An exit interview was conducted with Administrator Hiransha Keerthisinghe. A copy of the report an appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 28, 2021 · control 28-AS-20210923081002

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269(a)(21) · Plan of correction due date: Sep 28, 2021

Enumerated rights; severability. Residents of residential care facilities for the elderly shall have all of the following rights: To have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided, not to exceed two business days, at a cost not to exceed the community standard for photocopies. This requirement was not met by evidence of: Based on records review resident (R1's) responsible party requested resident records on September 13, 2021. Licensee provided resident records on September 17, 2021, exceeding the 2 working days per health and safety code of regulations.the state’s words, verbatim · CDSS document, Sep 28, 2021

Plan of correction: Administrator provided copies of resident (R1's) file records on September 17, 2021. A copy of the overnight receipt was provided to LPA. Deficiency is cleared.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced visit for the purpose of conducting the Required annual inspection. On today's visit LPA met with Administrator, Hiransha Keerthisinghe who assisted with the visit. LPA Rea discussed infection control practices with Administrator, toured the facility inside and out, reviewed food supply, reviewed staff files, and reviewed resident medications. Bedrooms have the required furniture including bedframes, dressers, lamps and chairs. Beds have the required linen and the linen is in good condition. Passageways and exits are free of obstruction. The front and back yards are well maintained. The resident bathrooms are clean and have the required grab bars in the shower and near the toilet for non-ambulatory residents. Showers also have non-skid materials. The hot water temperature measured at 113.7 degrees. The facility temperature at the time the visit was comfortable. There is sufficient lighting throughout the facility. There are smoke detectors/carbon monoxide detectors located throughout the facility. Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided to Administrator.the state’s words, verbatim · CDSS document, Jul 28, 2021

Type of visit: POC

Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced plan of correction (POC) visit at the facility. LPA Flores met with and explained the reason for the visit. LPA Flores conducted a case management visit on 7/14/21 and found the following deficiencies: 87465(e) Incidental Medical and Dental - PRN medications did not have labels on medication for Resident #3 and #5. 87608(a)(3) Postural Support - Half bed rails were observed in bedrooms #1, #2, #4, and #5. 87309(a)(1) Storage Space - cleaning chemical solutions and sharps were not kept under lock. During today's visit LPA Flores observed bed rail request for Resident's in bedroom #1,#2, #3,#4, #5. PRN Medication for R#3 and R#5 were label with resident's and medicine information and administrator certify on LIC 9098 that all PRN medication will be label with a pharmacy label. Cleaning supplies and sharps locks were working properly and kept under lock and administrator certify in LIC 9098. Deficiencies have been fixed and cleared. Exit interview was conducted and a copy of the report and POC letters was provided.the state’s words, verbatim · CDSS document, Jul 27, 2021

Type of visit: Case Management - Deficiencies

Licensing Program Analyst(s) (LPA) Mary Flores conducted a case management visit during a complaint investigation visit on 7/14/21. During the health and safety check conducted during the complaint investigation LPA observed the following: facility's kitchen sharps were kept on drawer next to stove and cleaning supplies kept in cabinet under sink , both have locks but do not lock properly and were not lock at the time of the visit. LPA checked rooms #1(R1),2(R2),3(R3),4(R4) each bedroom has all required bedding, and furniture. LPA observed full bed rails in R1,R2,R3,R4. LPA Flores reviewed Resident #1(R1),#2(R2)#3(R3), R4(R4),#5(R5) files and did not observed a physician's request for full rails, administrator stated to need to request from physician's. Medication for R1,R2,R5 was reviewed and facility had different PRN medication without a doctor's prescription for R3, and R5. Cleaning liquids were observed under Bathroom #3's sink, and were not under lock. Based on the above observations, deficiencies will be cited under Title 22, Division 6, Chapter 8 on LIC 809D. Exit interview was conducted with Hiransha Keerthisinghe, administrator and a copy of the report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 14, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(e) · Plan of correction due date: Jul 15, 2021

87465 Incidental Medical and Dental: (e) For every prescription andnonprescription PRN medication... there shall be a signed, dated written order from a physician,... maintained in the residents file, and a label on the medication.... This requirement is not met as evidence by: Based on observation licensee did not ensure all PRN medication for R3, and R5 have a physician's prescription and label this poses an immediate Health, Safety, or Personal Rights risk for persons in care.the state’s words, verbatim · CDSS document, Jul 14, 2021

Plan of correction: Administrator will ensure all PRN medications are label for each resident by certifying on LIC 9098 and will provide or schedule medication staff in service training by a pharmacist by 7/15/21.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87608(a)(3) · Plan of correction due date: Jul 15, 2021

87608 Postural Supports: (a) ... Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record.... This requirement is not met as evidence by: Based on observation facility did not ensure to kept, or obtain a physician's request for full bed rails for 4 out of 5 residents which poses an immediate health, safety, or personal rights to the persons in care.the state’s words, verbatim · CDSS document, Jul 14, 2021

Plan of correction: Administrator will request bed rail request for R1,R2,R4,R5 and will remove bed rails on empty bed in room #3 will submit each request and picture of bed in room #3 by 7/15/21.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a)(1) · Plan of correction due date: Jul 15, 2021

87309 Storage Space: (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. This requirement is not met as evidence by: Based on observation facility did not ensure all sharps and chemicals were kept under lock at all times which poses an immediate health, safety, or personal rights risk for persons in care.the state’s words, verbatim · CDSS document, Jul 14, 2021

Plan of correction: Administrator will ensure all chemical, cleaning solutions, sharp items are kept under lock at all times by certifying on LIC 9098 and will conduct or schedule an in-service training for staff on regulation 87309 by 7/15/21.