Aaspen Villagecare

Allegation investigated: Neglect of resident in care

Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegation noted above. LPA met with Lora Statler, House Manager. Administrator Christopher Tanabe was available via telephone. and explained the purpose of the visit and the elements of the allegation. The allegation was investigated, the investigation consisted of observation, interviews and record review. It was alleged that on or around May 18, 2021, Resident #1 (R1) was neglected by facility staff. R1 was reported to have been observed found with flies on their body, covered in blood, wound dressing missing, dried feces and blood on body, blankets covered in blood, finger covered in blood, eye crusts formed, and disheveled bedding. LPA reviewed resident observation logs dated May 17, 2021, R1 is noted to have had a bed bath, as well as their bedding changed. On May 18, 2021, revealed that R1 would pick the sores and heavily bleed as well as remove the dressing that was located on their right ear. The facility observation log notes that staff had to change, and clean R1 as they were observed to have blood on their fingers that were covered in blood. Further documentation dated May 18, 2021 further Unfounded documentation reviewed revealed staff reporting that R1’s gown and comforter had drops of blood, along with blood being collected on the chuck and soiled dressing on R1’s right ear, and that hospice was contacted to assist and change the dressing. R1 is noted on May 19, 2021, R1 had a visit with from the hospice agency staff who had provided wound care for R1 including have covered the wound on the right ear with a dressing/gauze. Per the facility observation logs 30 minutes after hospice left, R1 was noted to have removed their dressing again. The observation logs notes that facility staff contacted R1’s hospice agency at 12:05pm and was informed that they would send someone out. Facility staff is noted to having called the Administrator as hospice had not shown up as of 2:10pm, also noting that most of the blood was cleaned up. LPA conducted a physical visit to the facility on May 21, 2021. LPA did not observe any flies, in R1s room or flying around the facility. R1 was observed to be sleeping and noted to have clean bedding and clothing. LPA was unable to interview R1, due to them being asleep, and reported to be transitioning. R1 did not wake up at any point, during the time of LPAs visit. Per staff interviews conducted revealed that staff denied the allegation and stated that it has been an ongoing occurrence with R1 picking at their wound and removing the dressing, and that the bedding is changed as often as it is needed, as a result of the wound picking. Based on observation, interviews and record review the allegation of neglect of resident in care is UNFOUNDED. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was provided to Lora Statler, House Manager.the state’s words, verbatim · CDSS document, Sep 5, 2023 · control 18-AS-20210519091918

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Melody Brown arrived at the facility 02/17/2022 at 10:00 AM unannounced in order to complete the facility's Annual Inspection. LPA Brown met with House Manager Patricia Roggenbuck and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Administrator Christopher Tanabe was contacted and later arrived during the visit. Below is a summary of what was observed: Infection Control: LPA Brown went over COVID-19 best practices for infection control and prevention with House Manager Roggenbuck and Administrator Tanabe and they reported that Mitigation Plan was submitted January 2021. LPA Brown requested Administrator Tanabe to send a copy of Mitigation Plan via email. LPA Brown observed the facility having Covid-19 signages throughout the facility for proper hand washing procedure, social distancing. LPA Brown toured the inside and outside the facility and observed that there's no resident at the moment but Administrator Tanabe reported that they will have resident soon at the facility. LPA Brown observed resident bedrooms and bathrooms with paper towels and hand soap. LPA Brown requested to inspect the facility's Personal Protective Equipment (PPE) supply. LPA Brown observed the facility to have a sufficient supply of sanitizer, gloves, masks, and face shields/goggles or isolation gowns. LPA Brown went over the various recommended training for facility staff with Administrator Tanabe in relation to COVID-19 and informed Administrator Tanabe that once they have residents at the facility, staff needs to be trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing of PPE. Also, LPA Brown informed Administrator Tanabe that once they'll have residents, all staff need to be fit tested for N95 masks. *** Continuation in LIC809C *** LPA Brown will be providing Administrator Tanabe with the information for Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and their residents for COVID-19, when and how to isolate/quarantine residents, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. The facility also has a plan in place to monitor their residents regularly for any changes in condition and to subsequently notify the resident's physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses. Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted with Administrator Christopher Tanabe and a copy of this report (LIC 809) was discussed and provided.the state’s words, verbatim · CDSS document, Feb 17, 2022

Allegation investigated: Staff stole resident's medications. Staff did not meet incontinence needs of residents.

Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegation(s) listed above. LPA George identified herself and discussed the purpose of the visit and the elements of the allegation(s) with LPA was greeted and granted entry by Caregiver Cassandra Loe. Administrator Christopher Tanabe arrived shortly after LPA's arrival. Note that the facility is still temporarily closed. The investigation consisted of a review of pertinent documentation and interviews. Allegation: Staff stole resident’s medications. On 10/5/20 LPA conducted an interview with previous Administrator Crystal Green whom did confirm that resident #1 (R1) medication (Hydrocodone-Narcotic) did come up missing. Crystal stated that she does remember seeing the medication sitting on the desk, however the office was being cleaned and there was a bunch of papers and other things that needed to be organized or thrown in the trash. Crystal stated that she Unsubstantiated believes that the medication was tossed in the trash can, however, did not go looking in the dumpster for it to confirm and or to retrieve the medication. LPA interviewed S2 whom denied that they stole the medication. S2 confirmed that yes, they were the one that picked up the medication from the pharmacy and brought it straight back to the facility and placed it on the desk. However they were not able to be located once it came time to do. Administrator Crystal stated that she was going to file a police report but had not done so yet. Based on interviews and record review the allegation of Staff stole resident’s medications is UNSUBSTANTIATED. Allegation: Staff did not meet incontinence needs of residents. LPA conducted interviews and inquired about the resident and incontinent care. It was explained that the residents are checked every two hours, and that as needed if the resident were to inform staff that assistance was needed, by using their call button. The facility does not have a log documenting the times that incontinent care had been provided, but it is a known fact that resident’s need to be checked to ensure that their incontinent needs are being met. LPA conducted resident interviews and the feedback provided was that there are not any issues with their incontinent care and that if they have informed staff that they need to be changed, they will be changed as soon as they are finished completing a task, such as tending to another resident is the only time that they have to wait. Therefore, the allegation of Staff did not meet incontinence needs of residents is UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time.the state’s words, verbatim · CDSS document, Jul 2, 2021 · control 18-AS-20200925153619

Allegation investigated: Facility has rodents. Facility is malodorous.

Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegation(s) listed above. LPA was greeted and granted entry by Caregiver Cassandra Loe. LPA George identified herself and discussed the purpose of the visit and the elements of the allegation(s) with Administrator Christopher Tanabe whom arrived a few minutes later after LPA. The investigation consisted of a review of pertinent documentation and interviews. Allegation: Facility has rodents. On 12/14/20 LPA George conducted a tour of the physical plant and observed the following: black box (traps), outside of the facility once inside LPA observed droppings inside the hallway where the backup refrigerator and food is stored. LPA conducted a search inside of the cabinets and did not observe any droppings, however staff was hitting on the cabinets before opening them and stated that, “that is where the rodents (rats, and mice) were”. In addition, LPA reviewed documentation that revealed rodents running around inside * Continued on 9099C Substantiated and outside of the facility. On one occasion there were 5 rats and or mice grabbing food (slice of bread) outside of a black trash bag that was sitting in front of the facility by the gate. LPA interviewed Administrator Christopher whom stated that due to the infestation all the residents had been temporarily relocated to one of the Sister facility Aaspen Village care II #366423704. Based on observation, interview and record review the allegation of Facility has rodents is SUBSTANTIATED. This posed an immediate health and safety risk to residents in care. Allegation: Facility is malodorous On 12/14/20 LPA conducted a tour of the physical plant. Upon entry of the facility front door was an overwhelming odor, that is associated with deceased rodents. As a result, all residents had to be temporarily relocated to one of the Sister facility Aaspen Village care II #366423704. Interviews conducted and the feedback provided was the odor is overwhelming unhealthy and can make you sick and that the only reason why staff are still entering the facility is to get food out of the refrigerator. Based on observations and interview the allegation of Facility is malodorous is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. This posed an immediate health and safety risk to residents in care. An exit interview was conducted and a copy of this report and appeal rights was provided to Administrator Christopher Tanabe.the state’s words, verbatim · CDSS document, Jul 2, 2021 · control 18-AS-20201210141038

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a) · Plan of correction due date: Jul 3, 2021

1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (5) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment. Based on observation, interview and record review this requirement is not met as evidenced by: on 1 out of 1 times the resident’s were not accorded safe, healthful, and comfortable accommodations due to the rodent infestation. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 2, 2021

Plan of correction: The licensee agrees to have the residents relocated to the sister facility until the infestation has been eliminated. The licensee will also have the exterminator come and treat the facility as they recommend, the licensee will submit copies of the invoices to department by 5pm on the due date indicated.

Allegation investigated: Facility air conditioning is not working.

Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegation listed above. LPA George identified herself and discussed the purpose of the visit and the elements of the allegation(s) with LPA was greeted and granted entry by Caregiver Cassandra Loe. Administrator Christopher Tanabe arrived a few minutes after LPA's arrival. Note that the facility is still temporarily closed. The investigation consisted of a review of pertinent documentation and interviews. Based on observation and interviews LPA was able to corroborate the allegation. LPA interviewed Administrator Tammy Barnett whom stated that “yes the air conditioner was broken”. During the virtual tour conducted on 8/31/20, LPA observed staff fanning themselves with paper due to the air conditioner being broken in the office. In the resident bedrooms. LPA observed standing/floor fans being used as many as to 2 per room. Tammy explained that the electrician had come out on 8/28/20 and stated that he Substantiated needed to order additional parts because the back panel needed to be replaced, after changing all of the vents, the air conditioner has been working inconsistently off and on for about a month or so. Due to the air conditioner malfunctioning, 5 residents were moved rooms. The allegation of Facility air conditioning is not working is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. This poses an immediate health and safety risk to persons in care. An exit interview was conducted and a copy of this report and appeal rights was provided to Administrator Christopher Tanabe.the state’s words, verbatim · CDSS document, Jul 2, 2021 · control 18-AS-20200828160829

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(b)(1) · Plan of correction due date: Jul 3, 2021

87303 (b) (1) Maintenance and Operation (b) A comfortable temperature for residents shall be maintained at all times. (2) The facility shall cool rooms to a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat to 30 degrees F less than the outside temperature. Based on observation, interview and record review this requirement is not met as evidenced by: 1 out of 1 times the facility was not at a comfortable temperature. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 2, 2021

Plan of correction: The licensee agrees to have the air conditioner repaired and submit the invoices to the department by 5pm on the due date indicated.