Wesley Palms

Allegation investigated: Food is served cold Licensee did not pre-appraise residents Licensee did not meet residents needs

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings in the above complaint allegations. LPA identified herself and discussed the purpose of the visit with Executive Director Justin Webber On April 18, 2023, Community Care Licensing (CCL) received a complaint alleging food is served cold, residents are not being pre-appraised, and resident’s needs are not being met. During investigation, LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews. According to allegations, residents are receiving their food cold when meals are delivered to their rooms. During inspection on April 25, 2023, LPA Strong toured the kitchen and reviewed facilities dining protocol. According to staff interviews, residents have the option of in-person full dining service, picking up their food from the casual dining area or having their food delivered to their rooms; all options are available for three meals per day. Unsubstantiated Residents interviewed expressed that their food is not cold during in-person full dining service but may be cold when delivered to their rooms. Resident interviews also revealed that all residents have access to have their food reheated in their rooms or by the kitchen staff. LPA Strong reviewed facility’s protocol for keeping food warm prior to room delivery which included warming ovens, heat lamps and chaffing lines; all which were fully functioning at temperatures of 135 degrees Fahrenheit or above. Interview with Dining Service Director revealed that facility has been working on maintaining food temperatures during all meal services and recently purchased insulated bags and additional heating ovens. Records collected corroborated that the facility had been investing in temperature preserving strategies for meals. It was also alleged that facility is accepting resident without first conducting resident pre-appraisals though allegation did not identify specific residents. Interviews with staff revealed that all residents are pre-appraised, and it is documented in their individual files. LPA Strong conducted a random resident file review and found all resident files reviewed had a pre-appraisal documented prior to move in date. Interview with former Executive Director revealed that no residents had been admitted into the facility without a pre-appraisal. Lastly, it was alleged that staff are refusing to assist residents with activities of daily living, including showering, toileting, and bathing but no specific residents were identified. Interviews conducted with residents revealed that all resident’s needs were being met and no concern was discussed regarding lack of care. Interview with staff revealed that there have been no recent reports of resident not receiving the assistance they were assessed for. Interview with an outside source revealed that there were no prior complaints regarding resident’s needs not being met. Based on LPA's facility inspection, interviews, and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Executive Director Justin Webber, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, May 22, 2023 · control 08-AS-20230418160843

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Iby Strong conducted a case management visit to deliver an amended report. LPA met with Executive Director Justin Webber informed him of the purpose of the visit, and was granted entry. Today's visit is to deliver an amended report from complaint visit conducted on 04/25/2023. All staff present have a current criminal record clearance. The amended report was reviewed with Executive Director Justin Webber and signatures were obtained. An exit interview was conducted, Appeal Rights (LIC 9058 03/22) along with a copy of this report was provided to Executive Director Justin Webber.the state’s words, verbatim · CDSS document, May 22, 2023

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced case management visit to follow-up on an incident reported to Community Care Licensing. LPA met with Executive Assistant Rowena Lomboy, and discussed the purpose of the visit. Community Care Licensing received an incident report on 05/01/2023 in which it was reported that Resident #1 (R1) was physically injured by an unknown source. During today's visit, LPA collected pertinent resident records as well as conducted a health and safety check of the residents in care. No deficiencies were cited during today’s visit. Executive Assistant Rowena Lomboy was provided a copy of this report, appeal rights (LIC9058 03/22) and a LIC 811.the state’s words, verbatim · CDSS document, May 9, 2023

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Assistant Rowena Lomboy and Director of Resident Health Services Aurora Galicia. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office on 03/29/2023. According to the LIC624: in late March 2023, there were occasions when staff did not give (i.e., missed giving) Resident #1 (R1) their prescribed antibiotic medication. [See LIC 811 Confidential Names List for a description of person identifiers used in this report]. Staff first discovered the medication errors on 03/25/2023 and notified R1’s responsible party and physician that same day. The missed doses did not result in any visible adverse health consequence for R1. During today’s visit, LPA performed a brief facility tour and attempted a welfare check on R1, but R1 was off-site on an outing during LPA's visit. LPA interviewed pertinent staff and reviewed relevant records. Per their latest LIC602 Physician’s Report: to the stock questions of whether R1 was able to store and administer their own prescription medications, R1’s doctor checked the “Yes” boxes. However, the same doctor also diagnosed R1 with “Mild Cognitive Impairment.” Staff interviews revealed that, in practice: staff stored R1’s prescribed medications, R1 required staff help with safely taking their medications, and R1 was paying licensee for medication management services. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Staff interviews, corroborated by records, revealed: R1’s antibiotic was prescribed twice per day, for ten (10) days, starting on 03/15/2023; as such, the pharmacy dispensed twenty (20) pills to licensee. By 03/25/2023, licensee identified there were two (2) excess doses remaining in inventory, compared to what staff logged/initialed as given to R1 per the facility’s Medication Administration Record (MAR). Licensee’s internal investigation concluded R1 missed two (2) prescribed doses of their antibiotic medication, during a period of ten (10) days, and that the culpable staff was some combination of Staff #1 (S1), Staff #2 (S2), Staff #3 (S3), and/or Staff #4 (S4). Per manager interviews: On 03/26/2023, a supervisor provided informal remedial training to S1, S2, S3, and S4. Then on 03/29/2023, a nurse from licensee’s contracted pharmacy led a training class on medication administration practices/procedures for S1, S2, S3, S4, and all other staff involved in medication pass duties. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Galicia, to whom a copy of this report, the LIC 809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Apr 21, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: May 21, 2023

87465 Incidental Medical and Dental Care: “(a)(4) The licensee shall assist residents with self-administered medications as needed.” This requirement was not met, as evidenced by: Based on records and interviews, the licensee did not assist 1 of 317 residents (R1) with self-administered medications as needed/prescribed, which posed a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Apr 21, 2023

Plan of correction: On 03/26/2023, a supervisor provided informal remedial training to S1, S2, S3, and S4. Then on 03/29/2023, a nurse from licensee’s contracted pharmacy led a training class on medication administration practices/procedures for S1, S2, S3, S4, and all other staff involved in medication pass duties. Licensee agreed to E-mail LPA a copy of the sign-in sheet for the training led by the pharmacy, by the POC date.

Allegation investigated: -Residents are being left unsupervised -Facility is unsanitary

Licensing Program Analyst (LPA), Natasha Persaud concluded the complaint investigation regarding the above mentioned allegations. LPA met with Executive Director, Ben Geske During the course of the investigation, the facility was toured, and interviews conducted with staff, residents, and outside sources. It was reported memory care residents were left unsupervised in the assisted living portion of the facility. Outside source interviews reported memory care residents are confused and roaming around the facility unsupervised. The facility has a locked memory care unit, which requires a code to enter and exit. Staff interviews confirmed some memory care residents are rarely brought to the assisted living dining room to eat out on the terrace, but they are accompanied by staff at all times. Resident interviews revealed residents walk around indpedently but have not witnessed residents roaming as though they are lost, residents are supervised. Additional staff interviews verified residents are not left unsupervised that require supervision. Further staff interviews revealed the assisted living residents independently walk around the facility and may have some cognitive impairment but just need redirection, not memory care. Continued on an LIC 9099C. Unsubstantiated It was also alleged the facility is unsanitary. It was reported the facility had a urine odor on the second floor, and the kitchen floor is not being cleaned at night. On 05/13/22, LPA toured each floor of the facility from one end of the hall to the other. There was no urine odor, or any unwanted odors observed. The kitchen was observed with a couple pieces of lettuce on the floor, as they just finished serving lunch. Overall the kitchen and dining room was observed as clean and sanitary. Resident interviews confirmed the facility is kept clean and sanitary. Residents also denied an urine odor on the second floor. Staff interviews revealed the kitchen floor is swept daily and mopped most nights. Staff denied any urine odor on the second floor. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations are deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 01/16) were provided to Executive Director, Ben Geske whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Feb 23, 2023 · control 08-AS-20220506104912

Allegation investigated: Staff did not notify responsible parties of a resident's hospitalization

Licensing Program Analyst (LPA), Natasha Persaud conducted a complaint investigation regarding the above mentioned allegation. LPA identified herself and discussed the allegation mentioned above with Executive Director, Ben Geske and Executive Assistant, Robert Rubio. During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was reported staff did not notify responsible parties of resident's hospitalization. On 01/24/23, Resident #1 (R1) was transported to the hospital via 911, due to a fall at the facility. Outside source interviews revealed R1’s spouse also resides at the facility and is the Power of Attorney for R1. R1’s responsible party was not notified of R1’s hospitalization on 01/24/23. Outside source interviews confirmed R1’s responsible party was contacted for another fall that occurred on 02/06/23 but not the fall on 01/24/23. The facility has easy access to R1’s spouse/responsible party due to the spouse residing at the facility, yet the facility did not contact R1’s responsible party. The Executive Director’s (ED) interview revealed there's a notification procedure in place that requiers staff to notify the emergency contact during the shift the event occurred. In the event, the staff is unable to reach the emergecny contact/responsible party, it is the Substantiated responsibility of the next shift to follow up and contact the emergency contact/responsible party. The facility staff made an attempt to contact R1's family member but did not leave a message and no further attempts were made on the following shift. In addition, Community Care Licensing did not receive Incident Reports for either incident. Title 22 Regulation outlines incidents of certain circumstances shall be reported to CCL and the resident’s responsible party. The staff failed to notify R1’s responsible party. Based on interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 01/16) were provided to Executive Director, Ben Geske whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Feb 23, 2023 · control 08-AS-20230216111941

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Mar 23, 2023

Reporting Requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence...This report shall include the resident's name...and treatment, if any; and disposition of the case. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not submit a written incident report or notify R1’s responsible party or CCL for (R1) one out of 320 residents in care. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 23, 2023

Plan of correction: Executive Director stated they are enforcing their notification procedures for staff by having staff sign a Notification Procedure form and the supervisror will attest on the form they have trained the employee. Also, the procedure wiill be posted in the Wellness Center as a reminder to follow procedures. ED provided copy of the new Notification Procedures form. POC corrected.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Required 1 - Year Visit. The facility file was reviewed prior to the visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Assistant Robert Rubio. LPA conducted a brief tour of the facility and observed the staff and residents in care. In accordance with the Department’s Infection Control program, LPA provided technical assistance and observed and evaluated the facility's implementation of their COVID-19 Mitigation Plan, to include disinfection, screening protocols, and the use of personal protective equipment. No deficiencies were cited on this date. An exit interview was conducted with Rubio, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided.the state’s words, verbatim · CDSS document, Jan 30, 2023

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to follow up on events which licensee self-reported to the Community Care Licensing San Diego Regional Office (RO). LPA was welcomed by and identified himself to Receptionist Atsumi Oda. LPA then met and discussed the purpose of the visit with Executive Assistant Robert Rubio. On 01-25-2023, the RO received an LIC624 Unusual Incident Report regarding Resident #1 (R1) leaving the facility and not being able to find their way back home. The report said R1’s responsible party was notified and 911 was called. Law enforcement located R1 and returned them to the facility unharmed a few hours later. During today’s visit, LPA briefly toured the facility, performed a welfare check on R1, collected pertinent records, and interviewed relevant staff. Per their LIC602 Physician’s Report and staff interviews, R1’s doctor determined R1 was able to safely leave the facility unassisted. Records and interviews showed staff followed the facility’s Absentee Notification Plan for R1, and have planned a care conference with R1's responsible party. No deficiencies were identified or cited during today’s visit. An exit interview was conducted with Rubio, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 01/16) were provided.the state’s words, verbatim · CDSS document, Jan 30, 2023

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPA), Alexandre Vo and Rebecca Ruiz, conducted an unannounced Case Management Inspection to follow-up on previous incidents initiated on December 12, 2018. LPAs were allowed entry into the facility after identifying themselves and met with Executive Director, Ben Geske. LPAs explained the purpose of the visit. The Department’s investigation included review of inter-agency reports and facility records, as well as, interviews with staff, residents, and outside sources. The facility completed all their reporting requirements and submitted self-reported incidents to the San Diego Regional Office in December of 2018 regarding theft of residents’ credit/debit cards and subsequent fraudulent charges on the residents’ financial accounts. Incident reports indicate that Resident #1 (R1, see List of Confidential Names) had an unauthorized charge of approximately $1,000. Resident #2 (R2) was reported to have unauthorized purchases on December 4 and December 5, 2018. Resident #3 (R3) also had confirmed unauthorized purchases on their financial accounts on December 11, 2018. Based on records and interviews, it was determined that Staff #1 (S1, see List of Confidential Names) committed acts of fraudulence and theft against the financial welfare of elderly residents at the licensed community care facility. S1 assumed a family member’s identity and was hired on November 27, 2018. S1 was last seen at the facility on December 6, 2018. According to review of facility records and to interviews, it was corroborated that S1’s key card time stamps coincide with access to residents’ rooms on these dates during their employment. Facility records, law enforcement reports, and interviews also revealed that S1, while working as a private duty aid, used resident’s stolen financial information to pay for their personal AT&T bills. S1 subsequently plead guilty to four felony accounts including financial elder abuse violations on May 26, 2021 at San Diego County Superior Court that occurred between the time span of 2018-2019. S1 was sentenced to four years in local county prison. A citation is being issued in accordance with Health and Safety Code 1569.58 and listed on the LIC809D. A Plan of Correction was developed with the Executive Director and an exit interview was conducted. A copy of this report and Licensee’s Appeal Rights (9058 01/16) were provided to the Executive Director at the conclusion of the visit by electronic mail. A confirmation of receipt was requested.the state’s words, verbatim · CDSS document, Sep 14, 2021

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.58(a)(2) · Plan of correction due date: Oct 14, 2021

1569.58 Persons prohibited from ... holding certain positions or employment...(a)...a person who as done any of the following (2) Engaged in conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility... This requirement was not met as evidenced by: Based on records and interviews, S1 engaged in conduct that is inimical to the financial welfare of three of the 276 residents at the facility. This posed an potential financial risk to residents in care.the state’s words, verbatim · CDSS document, Sep 14, 2021

Plan of correction: S1/S2 was already terminated. Executive Director agreed to conduct in-service training regarding theft and loss policy. Executive Director agreed to submit training roster to LPA by POC.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Rebecca Ruiz, County of San Diego Nurse Contractors, Robert Montinallo and Elizar Perez, and California Department Public Health (CDPH), Health Facility Evaluator Nurse (HFEN), Maggie Turner with the HAI Program, conducted an on-site visit. LPA and team identified themselves and discussed the purpose of the visit with Administrator Ben Geske, Director of Resident Health Services Melanie Thompson, and Administrative Assistant Robert Rubio. The Department conducted an on-site visit to provide technical assistance and to evaluate the facility's mitigation plan to include disinfection, testing, vaccination, and screening protocols as well as the use of personal protective equipment (PPE). During today's visit, the team interviewed Administrator and the team conducted a walk-though of the facility. A debriefing was conducted with Ben Geske at the conclusion of the visit. During today's visit, no deficiencies were cited. An exit interview was conducted with the Administrator and a copy of this report, along with Licensee Rights (LIC 9058 01/16), were provided to the Administrator via electronic mail. An electronic receipt of confirmation was requested to be sent by the Administrator upon receipt of the documents.the state’s words, verbatim · CDSS document, Aug 5, 2021