Pine Hollow Care Home

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Talwinder Bains arrived on 09/21/23 to conduct the annual inspection. LPA met with administrator, Tatyana Matskevich who assisted LPA during today's inspection. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed residents (1) and staff files (1). All residents files contained the required paperwork. Staff file contained the required paperwork. Staff have current first aid and CPR training. Facility was clean. All required postings were observed. LPA reviewed medications of 1 resident comparing with physician orders and find no errors. LPA and Administrator toured the facility together to ensure the health and safety of residents in care. The areas toured included residents rooms, bathrooms, kitchen, common areas and outside area. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. All exits were unobstructed. The administrator's certificate is current. There is a gate for emergency access. LPA checked the kitchen area for the ability to prepare and store food. Knives and Sharp objects found to be locked . LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detector at the care home are operational. Fire extinguisher is ready for emergency use . Water temperature is within compliance (116 degree F) .Inside temperature was observed to be 77 degree F. In the areas toured, there were no health or safety violations were observed. LPA requested a copy of the LIC500, LIC610E and current liability insurance to be sent to the Department by 10/15/23. No deficiencies were observed or cited during today's visit. Exit interview conducted. A copy of this report was printed and given to Administrator.the state’s words, verbatim · CDSS document, Sep 21, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 09/15/2022 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with administrator- Tatyana Matskevich and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA confirmed that facility does not any positive covid-19 cases and nobody is experiencing any covid-19 symptoms today before facility entry. LPA wore the following Personal Protective Equipment (PPE) during today's visit: surgical mask. LPA was screened by facility administrator upon entry. LPA and administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, four (4) resident bedrooms, two (2) bathrooms, one ( 1 ) staff break room, kitchen, common areas and backyard area. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and administrator completed the infection control domain and facility was found to be in substantial compliance at this time. No deficiencies are being cited as a result of today’s inspection however Technical Advisory has been issued. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Sep 15, 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.

Allegation investigated: lack of care and supervision resulting in a resident sustaining an injury due to a fall

On 10/20/2021, Licensing Program Analyst (LPA) Jacob Williams arrived at the facility unannounced to deliver findings for a complaint Community Care Licensing (CCL) received on 10/01/2021 which alleged that “lack of care and supervision resulting in a resident sustaining an injury due to a fall”. LPA met with Administrator Tatyana Matskevich and explained the purpose of the visit. Prior to entering, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by staff and documented temperature in their visitor screening log. CONTINUED ON LIC9099-C Unsubstantiated Throughout the course of the investigation, CCL conducted interviews and reviewed documents. Interviews were conducted with residents R2-R5, Administrator, and R1’s Responsible Party (RP). Through interviews conducted, CCL learned that R1 would sometimes help himself to his room/bathroom without asking for assistance. On this day it was immediately following lunch time, and staff was working in the kitchen/dining area. R1 was sitting in front of television in living room when he decided to go to his bedroom without notifying the staff. His bedroom is around the corner from the living room, and before staff noticed he had moved, S2 heard his fall. Staff found R1 on the floor and asked him to stay on the floor while she called paramedics. Paramedics arrived shortly thereafter (within 10-20 minutes). CCL was informed that staffing was adequate the day of the fall, and R1 was regularly monitored by caretakers. CCL was unable to determine that R1’s fall was due to lack of care and supervision. Through interviews conducted, documents reviewed, and facility visits performed; CCL finds the allegation of Facility’s lack of care and supervision resulted in resident’s fall to be UNSUBSTANTIATED. A finding that the allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. There are no deficiencies being cited per Title 22 Regulations, Division 6, Chapter 8. Exit interview conducted. A copy of this report was left at facility.the state’s words, verbatim · CDSS document, Oct 20, 2021 · control 25-AS-20211001155803

Type of visit: Case Management - Incident

LPA Williams arrived on Friday, October 8, 2021 to open a separate complaint investigation. Prior to the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; LPA ensured he applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. LPA was screened at front door. LPA met with Tatyana Matskevich, Administrator, and requested an Appraisal/Needs and Services Plan, amongst other things. The facility does not have an Appraisal/Needs and Services Plan.the state’s words, verbatim · CDSS document, Oct 8, 2021

From the deficiency page — Deficiency type: Type B · Section cited: CCR 874579(c)(1) · Plan of correction due date: Oct 15, 2021

87457(c)Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs (1)The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors. Facility has not filled out a Needs and Services plan (LIC625) for resident which poses an immediate health and safety concern for the residentthe state’s words, verbatim · CDSS document, Oct 8, 2021

Plan of correction: Administrator to fill out resident's Needs and Service Plan (LIC625) or similar form, maintain it in resdient's file, and email a copy to Licensing by POC date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Williams arrived at the facility unannounced on 07/27/2021 to conduct a Required 1- Year Inspection utilizing the infection control domain. LPA met with Administrator, Tatyana Matskevic, and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted licensee and completed a facility risk assessment. LPA ensured he applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by facility staff upon entering the facility. LPA and staff toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, four (4) resident bedrooms, two (2) bathrooms, kitchen, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and administrator completed the infection control domain and facility was found to be in substantial compliance at this time. No deficiencies are being cited as a result of today’s inspection. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Jul 27, 2021