Oak Cottage of Santa Barbara Memory Care

Allegation investigated: Residents left in soiled diapers for a long period of time. Facility staff did not keep the facility premises in clean and sanitary condition at all times. Facility staff did not keep centrally stored medication locked.

Licensing Program Analyst (LPA) Kontilis conducted a subsequent complaint visit to the facility to issue final findings on this complaint. LPA met with Andrea Katz, Administrator and Jovany Guerra, Senior Generations Program Director. During the investigation, LPA conducted interviews with staff on 4/21/2021 at 3:50 pm, 4/28/2021 at 4:45 pm, 4/29/2021 at 12:50 pm, 3/13/2023 at 1:47 pm, 3/29/2023 10:14 am and 2:55 pm, and 3/30/2023 at 1:15 pm. LPA conducted interviews with a witness on 3/21/2023 at 2:19 pm, and interviews with responsible parties on 4/14/2022 at 4:55 pm. LPA also reviewed relevant documentation. On the allegation: Residents left in soiled diapers for a long period of time. LPA interviewed a staff, who stated they would arrive on their shift and would find “at least 90%” of the residents in wet/soiled diapers. Staff stated they found one resident “digging” in their diaper and had feces on their hand. Staff stated caregivers on the previous shift would not change the residents. Staff interviewed stated their job is to perform rounds and check on the residents. Staff stated residents are repositioned every 2 to 2.5 hours, are toileted or have their Please continue to 9099, Pg 2. Substantiated briefs checked. Staff stated their job is to change residents’ briefs so that they are dry. Multiple staff stated many times residents would have soiled diapers full of feces that had dried already, indicating it had been a long time since they were changed. Staff indicated sometimes residents had feces on their back or in their pants due to not being changed often enough. Staff stated on one occasion, a resident had it on their hands, body, face, on the bed, on the floor, and stated it was “everywhere.” LPA observed a photograph labeled Room 224 showing a pair of jeans that are soiled with feces. Based on the information obtained, the allegation is deemed Substantiated at this time. On the allegation: Facility staff did not keep the facility premises in clean and sanitary condition at all times. LPA interviewed staff, who stated staff on other shifts would not clean the facility areas and as a result the facility had a “bad smell.” Staff interviewed stated the floor, walls and toilets were dirty. LPA observed a photograph of a dirty floor in Room 223, showing brown spots on the floor. LPA observed a photograph of the toilet in Room 223, showing feces smeared on the toilet seat. Staff interviewed indicated resident’s rooms were dirty and dusty, the toilets were dirty with urine for multiple days, and the bathroom floor had spots of urine and was not cleaned timely. Staff interviewed indicated feces was also on the floor, and it would just be wiped and not deep cleaned. Responsible parties interviewed indicated resident rooms smelled of urine, the floor under resident beds was dirty and had trash, and the bathroom floor was dirty and sticky from urine. Responsible parties indicated they cleaned resident’s rooms on a few occasions due to the condition. Based on the information obtained, the allegation is deemed Substantiated at this time. On the allegation: Facility staff did not keep centrally stored medication locked. It was alleged that a medication was found on the counter of Room 220. LPA was provided a photograph showing a clear plastic cup filled with a brown liquid. There is no scale to the photo, but the cup appears to be a clear plastic drinking glass of at least 8 ounces. LPA was unable to determine if the cup contained medication or not, but it does not appear to be medication. Staff interviewed stated medications were kept locked. Witness interviewed indicated they were not aware of the medications being unlocked around the time of this complaint. One staff stated sometimes the medication room door was unlocked. During today’s visit at approximately 11:39 am, LPA observed the unlocked medication cart was unattended in the common area near several residents who were participating in an activity. LPA observed two residents walking near the medication cart. At the time of LPA's observation, Staff 1 (S1) approached the medication cart. S1 stated “I could have sworn the medication cart was locked." Please continue to 9099-C, Pg 3. Based on the information obtained, the allegation is deemed Substantiated at this time. LPA recommends the Administrator remind all staff that the medications need to be locked at all times. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): Exit interview conducted. Deficiencies cited on 9099-D. Copy of report and appeal rights issued at the time of the visit.the state’s words, verbatim · CDSS document, Apr 12, 2023 · control 29-AS-20210420120111

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Apr 17, 2023

…Residents…have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Based on interviews, the licensee did not ensure resident’s incontinence care needs were met, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 12, 2023

Plan of correction: Administrator agrees to conduct staff training with care staff (med techs, caregivers, duty aides) for incontinence care. Training to include date(s), Trainer's full name, title, description of training w/training roster with full name and signature of each trainee.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 17, 2023

87303(a) Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by: Based on interviews, the licensee did not ensure the rooms and bathrooms were clean from urine and feces, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 12, 2023

Plan of correction: Administrator agrees to provide a written statement acknowledging CCR 87303 in its entirety. Administrator agrees to provide facility's housekeeping schedule for April 12 through April 30, 2023.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Apr 14, 2023

87465(h)(2) Incidental Medical and Dental Care. Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidenced by: Based on observation, the licensee did not comply with the above cited section when LPA observed the medication cart was unlocked and unattended, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 12, 2023

Plan of correction: Administrator agrees to in-service training for protocol and regulation to keep the medication cart and medication room locked at all times. Training will be conducted by J. Guerra, Senior Generations Program Director and will include date(s) training was conducted, description of training, first and last names of trainees with signatures.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kristin Kontilis conducted a Case Management visit to address deficiencies noted during Complaint Control #29-AS-20210420120111 investigation visit conducted on 4/12/2023. LPA met with Andrea Katz, Administrator and Jovany Guerra, Senior Generations Program Director. Upon record review and interviews conducted, LPA determined CCL received no notifications of approximately 15 residents who were placed on hospice from 1/20/2022 through 1/13/2023. The facility currently has a hospice care waiver of 20. There are 10 residents currently receiving hospice services at this time. LPA counseled Administrator Katz on the importance of following the requirements in California Code of Regulations (CCR) 87632 Hospice Care Waiver. LPA recommended Administrator Katz review CCR 87632 in its entirety to determine if the facility can adhere to the CCR hospice care waiver requirements. Pursuant to Title 22, Division 6, Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted. Deficiencies cited. Copy of report and Appeal Rights issued.the state’s words, verbatim · CDSS document, Apr 12, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87632(d)(2) · Plan of correction due date: Apr 17, 2023

87632(d)(2) Hospice Waiver: The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above as CCL did not receive hospice notifications for approximately 15 residents placed on hospice from 1/20/2022 to 1/31/2023 which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 12, 2023

Plan of correction: Administrator agrees to conduct training with all staff responsible for submitting hospice notification. Training records will show full names of attendees, date of training, and person conducting training with first and last names in print and signature.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) De Leon conducted an on site 1 year infection control annual visit to the facility above on 02/27/2023 at 1:00 PM . LPA met with Business Office Director Staff Edith Martinez Flores and explained the purpose of the visit. Administrator Andrea Katz is out of the building today. Staff Building Services Director Benjamin Rodriguez took LPA on a physical plant tour of the facility. The facility has submitted a mitigation plan to the department. The facility has an entry point at the front door where everyone entering completes sign-in and symptom screening questionnaire. All documentation is kept on-file. The entry station has hand sanitizer. Medications are kept in a locked Medication room. The dining areas can accommodate distancing between residents when eating meals. The staff screen residents at a minimum of 1 x a day. Increased monitoring is conducted if any change of condition is noted. Signs are posted through out the facility regarding Covid-19. Staff make sure residents have a mask when leaving the facility on outings into the community. All staff wear face coverings in the facility and when on outings with residents. Facility has several areas for visiting inside, outside and in rooms. The facility also offers virtual and telephone communications to all residents in care. Staff, residents and visitors are informed of the facilities infection control policies. New residents will be tested and negative results received before residing in the facility. The facility has procedures and plans for screening, isolation, testing, when to call 911 and notifying all responsible parties and agencies when needed. Emergency Disaster plan has all agencies with telephone numbers listed. Administrator is in charge of infection control and provides training and education to staff, residents and visitors. Administrator is in charge of staffing and works on any issues or additional coverage. If any suspected or confirmed cases of Covid-19 are found in the facility staff will be assigned to only work with those quarantined/isolated individuals. Staff will use full PPE with N95 masks and face shields when dealing with any pending or confirmed cases of Covid-19. Continued 809-C Facility is able to dedicate a single room for resident so isolation can be arranged when and if needed. The facility has 40 resident apartments that all have own rest-rooms. The facility has 4 public rest-rooms which are well stocked with soap, paper towels and hand washing signs. Precautionary droplet signs will be posted on any room with quarantine or isolated individuals. PPE supplies will be located right outside those rooms when required. Facility has a 30 day supply of PPE on hand. Trash bins have tight fitting lids. Facility has plans for delivering medications and meals to any quarantined/isolation room. The facility has proper cleaning and disinfectant sprays. Facility Administrator has a plan in place for when and whom to notify in an outbreak or other emergencies. Administrator will keep a line list of all vaccinated and tested staff/residents in care with dates/results. Facility has conducted training on infection prevention, symptoms, transmission and PPE use. Facility has non-punitive sick leave polices for staff. Sick staff are requested to stay home and not report to work if ill. Activities have been modified to individuals or small groups with social distancing. Furniture has been moved around to accommodate social distancing. Residents medication is delivered in 30 day supplies to the facility. The facility ensures proper cleaning is done on frequently touched surfaces and between any individuals sharing of space or items. Staff and Resident records are kept in the locked office. The kitchen is clean and sanitary. Facility does realize guidance changes and the most up to date guidance from CCL-PINS, CDC, CDPH, and local health departments should be followed to remain in compliance. The most stringent orders should be followed. Fire Extinguishers are charged and last inspected on 01/19/2023. All Personnel working in the facility are cleared. No deficiencies observed during the visit and all infection control protocols are implemented and being followed. Exit interview completed and report printed and given to Business Director.the state’s words, verbatim · CDSS document, Feb 27, 2023

Allegation investigated: Due to staff neglect, resident suffered multiple falls resulting in injury. Facility staff did not meet Resident’s needs. Facility staff did not observe Resident's change of condition. Facility did not keep resident's room clean. Facility did not provide resident necessary toiletries.

Licensing Program Analysts (LPAs) Jeannette Olson and Kristin Kontilis conducted a subsequent complaint visit to issue final findings on the above-stated allegations. LPAs met with Jovany Guerra, Generations Program Director and explained the purpose of the visit. During the investigation, LPA Kotilis toured the facility on 6/22/2021 at 12:00 pm, interviewed the administrator at 11:23 am, interviewed the marketing director at 12:15 pm. LPA Kontilis also obtained copies of relevant documents. Medical records for R1 were subpoenaed on 10/18/2021. LPA Kontilis conducted additional interviews with staff on 4/12/2022 between 12:30 pm and 4:30 pm. LPA Kontilis conducted interviews with residents' responsible parties on 6/21/2021, on 4/14/2022 between 1:00 to 5:00 pm, and on 4/19/2022 at 8:08 am. LPA Kontilis toured the facility on 4/19/2022 at 1:30 pm and on 4/20/2022 at 11:40 am. LPA Kontilis interviewed Marketing Director and Generations Program Director during the visit on 4/20/2022. On the allegation: Due to staff neglect, resident suffered multiple falls resulting in injury. LPA Kontilis reviewed documents including R1’s physician’s report, pre-admission appraisal, assessment/care plan, incident reports, and a resident incident/accident log. R1’s physician’s report dated 10/7/2019 indicates R1 Substantiated has chronic traumatic encephalopathy, Alzheimer’s dementia, hypertension, is ambulatory, and ambulates without assistance. R1’s pre-placement appraisal dated 11/10/2019 indicates R1 is “a bit unsteady”; indicates R1 could slowly climb stairs if grab bars were available; indicates R1 is able to walk without any physical assistance including walker, crutches, or another person, or is able to walk independently with a cane; also indicates “sometimes” R1 is unable to walk independently with just a cane; indicates R1 uses a wheelchair but does not use a walker (contrary to physician’s report); and R1 does not need assistance moving about the facility. The pre-placement appraisal indicates R1 can transfer independently in and out of bed and can dress self, but a note was made R1 “is slow but can do it”; R1 could also toilet independently, and notes indicate “Can do. Usually! Well!”; R1 needs assistance with bathing, though another section indicates R1 only needs staff to “encourage” R1 to shower. The pre-placement appraisal indicates R1 needed observation at night to check their status. R1’s assessment completed by Jovany Guerra, Generation Program Director, on 11/12/2019 indicates R1 requires reminders to complete daily grooming; requires one staff assistance for bathing; indicates R1 has a prior history of falls within 6 months; indicates R1 does not have impaired functional mobility; indicates R1 has incontinence (contrary to physician’s report); indicates R1 did not require 1:1 care due to behaviors; and notes R1 uses a walker while ambulating (contrary to physician’s report and pre-placement appraisal). Updates to R1’s assessment include on 11/21/2019, vision assistance was needed with activities, reading mail, identifying objects; a shower chair was added; dressing assistance was required twice a day; grooming assistance was required; and status checks every 2 hours day and night were required. The assessment was updated again on 5/21/2020 to indicate R1 had a history of hip dislocations, and was updated again on 5/22/2020 to indicate R1 uses a wheelchair when being escorted to and from room. Incident Reports and Residence Incident/Accident log indicate R1 sustained falls on 1/6/2020 at 7:00 pm (fall); 2/9/2020 at 10:04 am (found lying on ground); on 2/9/2020 at 6:00 pm (fall); on 2/12/2020 at 3:00 am (found lying on ground); on 2/20/2020 at 2:00 am (fall); on 2/23/2020 at 3:45 am (fall); on 2/24/2020 at 5:15 pm (fall); on 2/26/2020 at 8:30 pm (transported to hospital); on 3/26/2020 at 8:50 pm (fall); on 4/20/2020 at 4:35 pm (fall); on 4/25/2020 at 11:05 am (fall); on 5/9/2020 at 9:00 pm (fall); on 5/19/2020 at 5:40 pm (fall); on 5/20/2020 at 6:00pm (transported to hospital); on 5/21/2020 at 5:15am (transported to hospital); and on 5/27/2020 at 9:40 am (found lying on ground). Overall, R1 sustained sixteen falls in five months. Records obtained do not indicate R1’s care plan was updated after the first thirteen falls and was only updated on 5/21/2020 and 5/22/2020. Please continue to 9099-C, Pg 3. Progress Notes indicate on 2/9/2020, staff noted R1 had been “very unsteady lately” but the care plan was not updated. On 2/11/2020, R1 was noted to be “anxious pacing up and down the halls and exit seeking” but R1’s care plan was not updated to indicate this new behavior. On 2/22/2020, R1 continued exit seeking behavior but R1’s care plan was not updated to indicate this new behavior. On 2/23/2020, staff noted R1 was “in wheelchair most of the day to avoid falls.” R1’s physician’s report was not updated to indicate R1 was using a wheelchair nor to indicate exit seeking behavior. The fall on 2/09/2020 required first aid for a skin tear on the right knee. After the fall on 2/20/2020, R1 went to the hospital where R1 was diagnosed with a dislocated hip. Medical records for 2/20/2020 indicate R1 had an unwitnessed fall and complained of hip pain, and confirm R1 sustained a dislocated hip. The fall on 2/24/2020 required first aid for rug burns sustained to the forehead and right knee. After the fall on 2/26/2020, R1 complained of right leg pain and was sent to the hospital, where R1 was diagnosed with another dislocated hip, as confirmed by medical records. Medical records indicate R1 was provided a knee immobilizer/brace and was discharged the next day back to the facility. Medical records instruct R1 to wear the knee immobilizer at all times for one week, until R1 follows up with an orthopedic surgeon. R1’s care plan was not updated to include these new instructions from the hospital regarding the knee immobilizer/brace. The fall on 4/20/2020 required first aid for carpet burns sustained on their right knee. After the fall on 5/21/2020, R1 went to the hospital. Medical records confirm on 5/21/2020, R1 was again diagnosed with a dislocated hip following the witnessed fall on 5/20/2020. Medical records indicate a knee immobilizer/brace was placed on R1 and hospital staff noted “staff at Oak Cottage notified of plan of care.” Instructions indicate to use the knee immobilizer for a “few days” to prevent recurrent dislocations. R1 was also given a wedge pillow from the hospital and instructions to use it to keep R1’s legs from being crossed. R1’s care plan was not updated to include the knee immobilizer/brace nor the wedge. In the facility’s Progress Notes, there are multiple entries showing R1 did not have the wedge in place and R1 kept removing the wedge. On 5/26/2020, Progress Notes indicate at 2:00am, R1 was observed with the wedge not in place and the leg brace was on incorrectly according to S4. Progress Notes indicate S4 showed S6 the correct way to put the brace on and how to place the wedge. Based on the information obtained, the facility did not appropriately update R1’s physician’s report or care plan after R1 experienced changes in condition. R1 sustained multiple falls, including three resulting in an injury of a dislocated hip, two resulting in carpet/rug burns, and one that resulted in a skin tear. R1 was discharged from the hospital with instructions to use a knee immobilizer/brace and wedge, but staff did not Please continue to 9099-C, Pg 4. use the knee immobilizer and wedge properly on at least one occasion. R1 also demonstrated exit-seeking behavior, but the physician’s report and care plan were not updated to indicate the behavior. It has been determined R1 sustained multiple falls and injuries. No evidence was obtained to indicate the facility attempted to meet R1’s needs by mitigating R1’s falls for the first thirteen falls sustained. Based on the information obtained, the allegation is deemed Substantiated at this time. A $500 immediate civil penalty for injury of a resident as the result of a deficiency is assessed today. The administrator was informed that additional civil penalties may be assessed based on Health and Safety Code 1569.49(f). On the allegation: Facility staff did not meet Resident’s needs. Responsible Party 1 (RP1) stated on 1/1/2020, RP1 visited R1 for the first time since R1 moved in to the facility on 11/21/2019. RP1 stated R1 appeared to be unkempt, needed a haircut, and was in dirty clothes. On 5/27/2020, RP1 was notified R1’s needs had increased and R1 needed 1:1 care. After 5/27/2020, RP1 provided 1:1 care to R1. RP1 stated RP1 gave R1 a sponge bath, cut R1’s nails because they were long, and shaved R1. LPA reviewed a shower schedule from 2020 and observed R1 was scheduled for a shower on 5/29/2020, after R1 had a 1:1 caregiver. S4 stated they felt R1’s hygiene needs were not met, along with other residents. During an interview, Generations Program Director (GPD) Jovany Guerra stated the shower schedule obtained was only a schedule and was not confirmation the showers happened as scheduled. Based on this information, facility staff did not meet R1’s hygiene and grooming needs. On 5/28/2020, RP1 suspected R1 had a Urinary Tract Infection (UTI) due to frequent urge to urinate. According to RP1, RP1 tried to find staff to assist R1 with toileting but could not find any staff. RP1 then assisted R1 to the bathroom fourteen times, due to the frequent urge to urinate. RP1 collected a urine sample because no staff could be found to assist. GPD Guerra stated the purpose of R1’s 1:1 was to provide additional supervision to try to prevent R1 from falling. During the interview, GPD stated in the past they had issues with facility staff believing they did not need to provide Activities of Daily Living (ADL) care to residents who had a 1:1 caregiver. GPD stated he addressed this concern with staff during an in-service training and clarified that facility staff must still meet the residents’ needs and provide care and supervision to residents for all matters including ADLs. GPD also clarified 1:1 caregivers are intended only for companionship and additional supervision. Based on this information, the facility staff did not meet R1’s toileting needs. On 5/21/2020, R1 was discharged from the hospital after sustaining a fall and dislocated hip. R1 was given a leg immobilizer/leg brace and was instructed to wear it for a “few days.” R1 was also provided a wedge pillow to position R1’s legs. R1’s care plan was not updated to include the leg immobilizer or wedge as part of R1’s care plan. On 5/26/2020, Progress Notes indicate at 2:00 am, R1 was observed with the wedge not in place and the leg brace was on incorrectly according to S4. Progress Notes indicate S4 showed Please continue to 9099-C, Pg 5. S6 the correct way to put the brace on and how to place the wedge. R1’s needs were not met when staff put the leg brace on R1 incorrectly. R1 requiring 1:1 care for falls did not absolve the facility of their responsibility to provide care and supervision to R1 as outlined in R1’s care plan. In addition, R1’s care plan was not updated to include the leg immobilizer and wedge, and staff put on R1’s leg brace incorrectly. Therefore, based on the evidence obtained, the allegation is deemed Substantiated at this time. On the allegation: Facility staff did not observe Resident's change of condition. R1’s physician’s report dated 10/7/2019 indicates R1 does not have bladder or bowel impairment, and cares for their own toileting needs. On 11/21/2019 the care plan was updated to include transfer assistance with one staff, use of a toilet riser, and notes that R1 “requires assistance for toileting and escort.” Progress notes indicate staff provided R1 assistance with toileting or changed R1’s brief. R1’s care plan had been updated 11/21/2020 to indicate R1 required status checks every 2 hours day and night. On 5/27/2020, RP1 was notified R1’s needs had increased and R1 needed 1:1 care. After 5/27/2020, RP1 provided 1:1 care to R1. On 5/28/2020, RP1 suspected R1 had a UTI, but RP1 was unable to obtain a urine sample because R1 could not produce enough urine to sample. RP1 obtained a urine sample on 5/29/2020 and provided it to Staff 3 (S3). RP1 stated they observed a courier pick up the sample that afternoon. Progress notes from 5/29/2020 at 8:48pm indicate R1 had the urge to urinate frequently and R1’s doctor was informed and a urine sample was requested. According to RP1, S3 stated they had obtained an antibiotic for R1. On 5/30/2020, R1 continued to have bladder and back pain, and had frequent urination. RP1 asked Staff 5 (S5) about the antibiotic, and S5 confirmed they did not have an antibiotic for R1 and no antibiotics were listed on R1’s med sheet. RP1 called R1’s physician and described R1’s symptoms including frequent urination and back pain. R1’s physician prescribed an antibiotic for R1. RP1 then picked up the prescription from CVS pharmacy. Facility’s plan of operation, page 12, indicates the assisted living director or designee will immediately notify the physician by phone if a resident experiences a change in condition. The plan of operation also states the physician recommendations will be followed and this information will be documented and kept on file at the community. GPD Guerra stated the purpose of R1’s 1:1 was to provide additional supervision to try to prevent R1 from falling. During the interview, GPD stated in the past they had issues with facility staff believing they did not need to provide Activities of Daily Living (ADL) care to residents who had a 1:1 caregiver. GPD stated he addressed this concern with staff during an in-service training and clarified that facility staff must still meet the residents’ needs and provide care and supervision to residents for all matters including ADLs. GPD also clarified 1:1 caregivers are intended only for companionship and additional supervision. Facility staff did not Please continue to 9099-C, Pg 6. contact R1’s physician about the change in condition and did not obtain the medication that was ordered. Instead RP1 contacted R1’s physician about the change in condition and obtained the ordered medication. R1 requiring 1:1 care for falls did not absolve the facility of their responsibility to provide care and supervision to R1, including observation of the resident for changes in condition and ensuring R1 received timely medical attention for the suspected UTI. Therefore, based on the evidence obtained, the allegation is deemed Substantiated at this time. On the allegation: Facility did not keep resident's room clean. RP1 stated R1’s floor was dirty under the bed, the room smelled of urine, and candy wrappers were observed on the floor under and behind furniture. LPA observed photos provided by RP1 and observed seven pieces of paper or tissue wadded up on the ground, between a nightstand and the wall, next to the bed. LPA also observed another photo showing shoes on the ground along with two tissues. S4 stated R1’s clothes and shoes were often not where they were supposed to be. Responsible Party 2 (RP2) stated Resident 2 (R2)’s room smelled of urine, and the bathroom floor was dirty and sticky from urine. RP2 stated RP2 cleaned R2’s room on a few occasions due to the condition. S4 stated residents’ rooms were dirty and dusty, the toilets were dirty with urine for multiple days, and the bathroom floor had spots of urine and was not cleaned timely. On 4/19/2022, LPA toured the facility with Generations Program Director. At 2:14 pm, LPA observed room 219 had a strong odor of urine. At 2:22 pm GPD requested housekeeping to attend to the urine in the room. Based on the information obtained, the allegation is deemed Substantiated at this time. On the allegation: Facility did not provide resident necessary toiletries. RP2 stated on at least three different occasions, they had to ask staff for toilet paper for R2’s room because there was none. RP1 stated they observed R1’s bathroom was lacking toilet paper on 1/1/2020. On 4/19/2022, LPA Kontilis toured the facility and observed no toilet paper on the toilet paper holder, nor anywhere else in the bathroom shared by Rooms 210 and 211. LPA photographed the empty toilet paper holder. LPA observed toilet paper on the counter of Room 210 and observed no toilet paper on the counter of Room 211. The counter where toilet paper was observed in Room 210 was not within reach of the toilet and is separated by a door. Based on the information obtained, the allegation is deemed Substantiated at this time. Exit interview conducted. Copy of report emailed. Deficiencies cited on 9099-D. Civil penalty issued. Appeal rights issued. 5/28/2020, RP1 suspected R1 had a UTI, but RP1 was unable to obtain a urine sample because R1 could not produce enough urine to sample. RP1 obtained a urine sample on 5/29/2020 and provided it to Staff 3 (S3). RP1 stated they observed a courier pick up the sample that afternoon. According to RP1, S3 stated they had obtained an antibiotic for R1. On 5/30/2020, R1 continued to have bladder and back pain, and had frequent urination. RP1 asked Staff 5 (S5) about the antibiotic, and S5 confirmed they did not have an antibiotic for R1 and no antibiotics were listed on the med sheet. RP1 called R1’s physician and described R1’s symptoms including frequent urination and back pain. R1’s physician prescribed an antibiotic for R1 over the phone and sent the order to a local pharmacy. RP1 then picked up the prescription from CVS pharmacy. LPA observed the antibiotic listed on R1’s MAR for June 2020. The MAR shows the medication order was effective starting on 5/31/2020 and it is recorded R1 received a dose on 6/1/2020, before moving from the facility. An interview with Generations Program Director (GPD) Jovany Guerra revealed when a new medication is ordered for a resident, the facility’s procedure is to contact the resident’s typical pharmacy and ask it to be filled. GPD stated most residents use the Omnicare pharmacy through CVS, which delivers three times per day to the area. For urgent medications that must be started as soon as possible, the facility is able to contract with the local CVS pharmacy for the medication to be delivered quickly. GPD also stated sometimes family members prefer to fill the prescriptions and bring them directly to the facility. RP1 obtained the antibiotic for R1 to ensure the medication was provided timely to R1. Based on the information obtained, there is not sufficient evidence to prove that the facility did not properly assist R1 with medications. Therefore the allegation is deemed Unsubstantiated at this time. Facility was advised that as a best practice, to ensure adequate communication with responsible parties at all times, particularly when a resident has a newly ordered medication. On the allegation: Facility staff gave Resident/Resident’s Responsible Party a verbal 24-hour eviction notice. Administrator stated they have never had to serve an eviction notice. Administrator stated they have given verbal notices. Administrator stated if a resident needs a higher level of care, they discuss relocating and give the families “a couple of days or weeks.” Administrator stated “we give it” by telephone or face to face, and again reiterated it is usually a verbal discussion. Administrator stated we have asked family members to find one-on-one care. RP1 stated the facility verbally told RP1 that R1 needed a higher level of care, and needed a 1:1 caregiver or would need to move out. The facility provided R1’s responsible party with an alternative to incurring the considerable expense of having R1 receive 1:1 care as provided for in R1’s admission agreement. Although this cannot be considered a 24-hour verbal eviction notice, this would be considered a Please continue to 9099-C, Pg 3 a verbal 24-hour eviction notice, this would be considered a change in R1’s level of care needed. The facility should have provided RP1 a 2-day written notice about the increased care needs. The 2-day written notice shall include an explanation as to why a 1:1 caregiver was needed and that RP1 had the choice for the facility to provide a 1:1 staff at a prescribed rate or RP1 could hire their own 1:1. The facility’s plan of operation Residence and Care Agreement, page 9, states “If it is determined by the Community staff that you are a danger to yourself or others, you may be required to receive one-on-one care and supervision for an additional charge as set forth in Appendix A, or for the cost of all services provided by Outside Provider and billed directly to you.” In addition, the facility should have issued a proper, written eviction notice if they intended to evict R1 due to needing a higher level of care. The facility should have also updated R1’s care plan to include R1 was reappraised and required 1:1 care due to falls. LPM and LPA explained regulations requiring proper 2-day written notice of increased care needs and eviction procedures to GPD on 4/20/2022. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the allegation. Therefore, the allegation is Unsubstantiated at this time. The facility will be cited on a case management report for failure to update R1’s care plan appropriately. An Advisory Note for Technical Assistance was issued to counsel the administrator that verbal evictions are not considered proper evictions per Title 22, and an Advisory Note for Technical Assistance was issued to counsel the administrator on proper 2-day written rate increases. On the allegation: Facility did not allow Resident(s) to have visitors. RP1 stated R1 moved into the facility on 11/21/2019. RP1 stated the staff told RP1 not to visit R1 for two months during R1’s settling in process. RP1 stated staff told them a transition period was “essential” and RP1 would not be able to see R1 for a period of time until facility staff “felt sure” R1 had “adjusted.” RP1 stated they felt like they “could not enter the facility.” As a result, RP1 stated RP1 did not visit R1 over Thanksgiving and Christmas. RP2 stated staff discouraged them from visiting and they were told not to come visit after R2 moved in, to let R2 adjust. According to RP2, the facility staff recommended the resident “disassociate” from their family to adjust to the new environment. RP2 stated they did not comply with that recommendation and visited anyway to ensure R2 was adjusting to the facility. RP2 stated facility staff “frowned upon this” and told RP2 it was best to let R2 settle in. During the interview on 6/22/2021, the Marketing Director stated transition is sometimes difficult for new residents. The Marketing Director stated they tell new residents their home is undergoing construction and tell the family members it may be beneficial to refrain from visiting the resident during the transition. LPA counseled the Please continue to 9099A-C, Pg 4. Marketing Director on the importance of accurately messaging the recommendation that residents may experience a better transition into the facility if visitors refrain from visiting, and explained about residents’ personal rights. On 4/20/2022, the Marketing Director stated visitors have never been denied entry into the facility. The Marketing Director stated she recognized the need to change the messaging about the recommendation, and now emphasizes resident’s personal rights during the discussion. In an interview on 4/20/2022, Generations Program Director (GPD) confirmed they alert families/responsible parties as to how the residents are transitioning after moving into the facility. GPD stated if they observe a resident to be agitated after a visit or phone call, they will alert the family/responsible party. GPD confirmed they have never turned away a visitor, and made great efforts to allow for safe visitation during the COVID-19 pandemic. Multiple responsible parties interpreted the facility’s messaging as they could not visit the residents during the transition phase. However, the facility allowed visitation for responsible parties that refused to comply with the policy. An Advisory Note for Technical Assistance was issued to emphasize the importance of accurately messaging the visitation policy to responsible parties and all other visitors. Based on the evidence obtained, the allegation is deemed Unsubstantiated at this time. Exit interview conducted. Copy of report emailed. Advisory Notes issued and emailed. Facility staff did not contact R1’s physician about the change in condition and did not obtain the medication that was ordered. Instead RP1 contacted R1’s physician about the change in condition and obtained the ordered medication. R1 requiring 1:1 care for falls did not absolve the facility of their responsibility to provide care and supervision to R1, including observation of the resident for changes in condition and ensuring R1 received timely medical attention for the suspected UTI. Therefore, based on the evidence obtained, the allegation is deemed substantiated at this time. On the allegation: Facility did not keep resident's room clean. RP1 stated R1’s floor was dirty under the bed, the room smelled of urine, and candy wrappers were observed on the floor under and behind furniture. LPA observed photos provided by RP1 and observed seven pieces of paper or tissue wadded up on the ground, between a nightstand and the wall, next to the bed. LPA also observed another photo showing shoes on the ground along with two tissues. S4 stated R1’s clothes and shoes were often not where they were supposed to be. Responsible Party 2 (RP2) stated Resident 2 (R2)’s room smelled of urine, and the bathroom floor was dirty and sticky from urine. RP2 stated RP2 cleaned R2’s room on a few occasions due to the condition. S4 stated residents’ rooms were dirty and dusty, the toilets were dirty with urine for multiple days, and the bathroom floor had spots of urine and was not cleaned timely. On 4/19/2022, LPA toured the facility with Generations Program Director. At 2:14 pm, LPA observed room 219 had a strong odor of urine. At 2:22 pm GPD requested housekeeping to attend to the urine in the room. Based on the information obtained, the allegation is deemed Substantiated at this time. On the allegation: Facility did not provide resident necessary toiletries. RP2 stated on at least three different occasions, they had to ask staff for toilet paper for R2’s room because there was none. RP1 stated they observed R1’s bathroom was lacking toilet paper on 1/1/2020. On 4/19/2022, LPA toured the facility and observed no toilet paper on the toilet paper holder, nor anywhere else in the bathroom shared by rooms 210 and 211. LPA photographed the empty toilet paper holder. LPA observed toilet paper on the counter of room 210 and observed no toilet paper on the counter of room 211. The counter where toilet paper was observed in room 210 was not within reach of the toilet and is separated by a door. Based on the information obtained, the allegation is deemed Substantiated at this time. Exit interview conducted. Copy of report emailed. Deficiencies cited on 9099-D. Civil penalty issued. Appeal rights issued.the state’s words, verbatim · CDSS document, Apr 21, 2022 · control 29-AS-20210614172310

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Apr 26, 2022

87468.1(a)(2) Personal Rights of Residents in All Facilities: Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not ensure R1 was accorded safe, healthful and comfortable accommodations due to the numerous falls and injuries sustained, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 21, 2022

Plan of correction: GPD agrees to provide a written plan, including but not limited to detailing how the facility will meet the needs of residents requiring care and supervision services related to fall risks, residents requiring 1:1 care, and changes in condition. GPD will submit plan to CCL by 4/26/2022, due to administrator being out of the facility. CIVIL PENALTY ASSESSED

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Apr 26, 2022

…Residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not ensure R1 received care, supervision, and services to meet R1’s needs, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 21, 2022

Plan of correction: GPD agrees to provide a written plan, including but not limited to detailing how the facility will meet the needs of residents requiring care and supervision services related to fall risks, residents requiring 1:1 care, and changes in condition. GPD will submit plan to CCL by 4/26/2022, due to administrator being out of the facility.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Apr 26, 2022

87466 Observation of the Resident. The licensee shall ensure…residents are regularly observed for changes in physical, mental, emotional…social functioning…appropriate assistance is provided when…observation reveals unmet needs...changes such as...deterioration of...physical health condition are observed, the licensee shall ensure that…changes are documented…brought to the attention of the resident's physician…the resident's responsible person...This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not ensure R1 was observed for changes in condition and R1’s physician was notified timely, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 21, 2022

Plan of correction: GPD agrees to hold an in-service training with caregivers and med-techs on recognizing changes in condition and the facility’s policy/procedure regarding a change in condition. GPD will submit training log to include time and date of training, and attendees (printed/signed) to CCL by 4/26/2022, due to administrator being out of the facility.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 26, 2022

87303(a) Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: Based on interviews, the licensee did not ensure the rooms and bathrooms of R1 and R2 were clean from urine and debris, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 21, 2022

Plan of correction: GPD agrees to hold in-service training to provide expectations to housekeepers, and to remind caregivers they should promptly notify housekeeping when additional room cleaning is needed. GPD will submit training log to include time and date of training, and attendees (printed/signed) to CCL by 4/26/2022.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(D) · Plan of correction due date: Apr 26, 2022

87307(a)(3)(D) Personal Accommodations and Services: …The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: Hygiene items of general use such as soap and toilet paper. This requirement was not met as evidenced by: Based on interviews, the licensee did not ensure toilet paper was provided to 2 out of 2 residents (R1, R2), which posed a potential health and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 21, 2022

Plan of correction: LPA observed basic hygiene items in each bathroom during the visit on 4/20/2022. POC cleared during visit.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Olson and Kontilis conducted an unannounced visit to the facility. While investigating complaint # 29-AS-20210614172310, LPA Kontilis noted the following deficiencies. Resident 1 (R1)’s care plan was not updated timely after multiple changes in condition. R1 sustained sixteen falls in five months. Records obtained do not indicate R1’s care plan was updated after the first thirteen falls, and was only updated on 5/21/2020 and 5/22/2020. After the fall on 2/26/2020, R1 was diagnosed with a dislocated hip. Medical records indicate R1 was provided a knee immobilizer/brace and was discharged the next day back to the facility. Medical records instruct R1 to wear the knee immobilizer at all times for one week, until R1 follows up with an orthopedic surgeon. R1’s care plan was not updated to include these new instructions from the hospital regarding the knee immobilizer/brace. After the fall on 5/21/2020, R1 was again diagnosed with a dislocated hip following the witnessed fall on 5/20/2020. Medical records indicate a knee immobilizer/brace was placed on R1 and “staff at Oak Cottage notified of plan of care.” Instructions indicate to use the knee immobilizer for a few days to prevent recurrent dislocations. R1 was also given a wedge pillow from the hospital and instructions to use it to keep R1’s legs from being crossed. R1’s care plan was not updated to include the knee immobilizer/brace nor the wedge. In the facility’s Progress Notes, there are multiple entries showing R1 did not have the wedge in place and R1 kept removing the wedge. On 5/26/2020, Progress Notes indicate at 2:00am, R1 was observed with the wedge not in place and the leg brace was on incorrectly according to S4. Progress Notes indicate S4 showed S7 the correct way to put the brace on and how to place the wedge. In addition, on 2/11/2020 R1 was noted to be “anxious pacing up and down the halls and exit seeking” and on 2/22/2020, R1 continued exit seeking behavior but R1’s care plan was not updated to indicate this new behavior. On 2/23/2020, staff noted R1 was “in wheelchair most of the day to avoid falls.” R1’s physician’s report was not updated to indicate R1 was using a wheelchair nor to indicate exit seeking behavior. Based on the information obtained, the facility did not update R1’s care plan after multiple changes in condition. Continued on 809-C During a tour related to the complaint on 4/19/2022, LPA Kontilis observed an electric tea kettle plugged in Room # 213. Generations Program Director (GPD) removed the tea kettle from the room during the visit at 2:46pm. Exit interview, deficiencies cited on 809-D, report emailed, appeal rights emailed.the state’s words, verbatim · CDSS document, Apr 21, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Apr 26, 2022

87463(a) Reappraisals. The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. This requirement was not met as evidenced by: Based on interviews and record review, the facility did not ensure R1’s appraisal was updated to reflect significant changes, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 21, 2022

Plan of correction: GPD agrees to provide a written statement of understanding of section 87463 by 4/26/2022.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87705(d) · Plan of correction due date: Apr 26, 2022

87705 Care of Persons with Dementia. In addition to requirements specified in Section 87303, Maintenance and Operation, safety modifications shall include, but not be limited to, inaccessibility of ranges, heaters, wood stoves, inserts, and other heating devices to residents with dementia. This requirement was not met as evidenced by: Based on observation, the facility did not ensure residents with dementia did not have access to an electric tea kettle, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 21, 2022

Plan of correction: GPD agrees to implement a plan to increase room checks for residents to ensure residents do not have access to unsafe items. GPD will send a copy of the plan by 4/26/2022.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Jeannette Olson and Kristin Kontilis conducted an unannounced on-site one-year infection inspection control visit to the above-named facility. LPAs began the inspection at 2:30 pm. A Mitigation plan has been submitted to CCLD. LPAs met with Jovany Guerra, Generations Program Director. Administrator Andrea Katz was not available at the time of the inspection. LPAs explained the purpose of the visit. The facility is a two-story secured perimeter Residential Care Facility for the Elderly (RCFE). There are currently 43 residents in care with a Dementia diagnosis. Currently, there are eleven (11) residents on hospice. The facility has submitted a Mitigation Plan to the Department. The facility has an entry station at the front door of the facility. Upon entry, staff, visitors, and clients who are returning from an outing are required to sign-in, and have a temperature screening. All documentation is kept in a locked filing cabinet in the Administration office located on the first floor of the facility. Screening documentation is stored in the facility basement. Bulk supplies of PPE gear, hand sanitizer, disinfecting wipes, disinfecting spray, gloves, and masks are kept in the facility basement. A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster, bill of rights and Resident’s Rights. LPA inspected the facility for fire safety, personal accommodations, and food service. The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked. The facility was seen to be in good repair inside and outside. Fire inspection was conducted on 5/10/2021. There are five (5) fire extinguishers. Each resident's room has a dual smoke alarm and carbon monixide detector. First Aid kits are kept in the Medication area of the Nurse's station on Floor 2, the kitchen and reception area on Floor 1. LPA observed the kitchen cabinets, refrigerator, and stove are clean. There is a sufficient amount of 2-days of perishable and 7 days of non-perishable foods. Please continue to 809-C, Pg 2. Residents participate at will in activities such as but not limited to exercise classes, pet therapy, nature walks, puzzles, games, Happy Hour, virtual travel tours, excursions to local eateries, and scenic rides. Residents are assisted with Assisted Daily Living (ADLs) needs such as toileting, bathing, showering, eating, feeding, transferring, laundry tasks, light housekeeping, and medication administration. The front are of the facility consists of a patio for visitation, concrete steps, concrete ramps and concrete walkways. The back patio has a barbeque and outdoor furniture conducive for visitation. The facility has 40 resident rooms. There are 4 shared bedrooms and 7 shared bathrooms. Each bedroom has a bed, nightstand, and lights to provide sufficient lighting. All staff associated with the facility have criminal record clearance. Exit interview conducted. Copy of report emailed. No deficiencies noted.the state’s words, verbatim · CDSS document, Apr 21, 2022