Lavender Hills Assisted Living II

Allegation investigated: Facility did not administer medications as prescribed. - SUBSTANTIATED Facility interfered with resident sending or receiving mail correspondence in a prompt manner - SUBSTANTIATED Facility did not contact responsible party in a timely manner. - SUBSTANTIATED Facility did not provide 30-day notices prior to moving residents to other rooms in the care home. - SUBSTANTIATED

Licensing Program Analyst (LPA) Rebecca Knight arrived unannounced to deliver findings to a complaint received on 12/27/2022 that was investigated by LPA Sabrina Calzada. LPA Knight met with administrator Jennifer Boss, Licensee Jant Coulter, and Naitasha Peerman - administrative assistant. LPA and explained the reason for the inspection. During the investigation, LPA Calzada interviewed (6) caregiver/Med-Tech staff who had provided care and supervision to resident (R1) during her residency at the community (“facility”) from 5/11/2018 through 7/10/2022, as well as the Licensee, Administrator and (2) Ombudsman. LPA was provided with substantial written documentation pertaining to the allegations from a family member, who was (R1’s) Designated Health Care Representative/Durable Power of Attorney and interviewed a second family member of (R1). LPA also reviewed multiple pieces of documentation provided to the Department, including e-mails between the Licensee and POA, incident reports (LIC624), resident charting notes, staff training records, Admission Agreement, and other documentation. Continued no LIC9099-C Substantiated Page 2 The resident was never conserved and (R1) was determined to have “intact cognitive function” following a Neuropsychiatric Assessment on 4/2/2021, until 4/14/22, when a follow up assessment was conducted. On the Physician’s Report, dated 5/3/21, it is noted (R1) had a diagnosis of Congestive Heart Failure (CHF), Hypertension (HTN), Coronary Artery Disease (CAD), Gastrointestinal Bleeding (GI bleed) and can bathe, feed and dress/groom herself and care for her own toileting needs. The physician’s report does not indicate that (R1) had a diagnosis of Mild Cognitive Impairment (MCI) or Dementia, and the only allergy noted is for quinolones (bactericidal antibiotics). (R1’s) care plan completed on 5/27/21 notes (R1) has additional diagnoses of Chronic obstructive pulmonary disease (COPD), walks with her walker most of the time and is able to perform most of her Activities of Daily Living (ADL’s) with some help and gentle reminders from staff. An updated physician’s report was obtained on 4/12/22 from the same physician. The primary diagnosis is listed as HTN and CHF with secondary diagnoses noted as Hyperlipidemia, Hypothyroidism, Urinary Retention and Atrial fibrillation (Afib). The physician’s report documents (R1) to have MCI, visual impairment, bladder impairment, is able to provide self-care for the same (ADL’s), is able to administer her own medications but is not able to administer her own oxygen. The only allergy noted is for quinolones. (R1’s) care plan completed on 4/10/22 notes (R1) to have additional diagnoses of Chronic obstructive pulmonary disease (COPD), Chronic UTI’s and a GI bleed and is able to perform some of her ADLs with assistance and gentle reminders from staff. (R1) was determined on 4/14/22, by her primary care physician, to be unable to make her own health care decisions. The results of the investigation are as follows: Continued on LIC9099-C Page 3 Allegation: Facility did not administer medications as prescribed. Complaint alleges that 1- resident (R1) received another resident's medication, 2- the facility did not follow up on a medication needed for resident's (R1’s) UTI, and 3- resident(R1) did not receive medication for 3 days and has a history of UTIs. 1-LPA reviewed an e-mail sent on 5/25/2022 from the Licensee to inform POA that (R1) was mistakenly given another resident’s medication, 50 mg. Pregabalin for nerve pain and 25 mg. Hydralazine, a blood pressure medication, and (R1) is doing fine. Licensee states that staff “immediately followed proper protocol and called the administration, the pharmacy, the doctor, and then we called 911 who evaluated resident in person and said resident was fine, perform a health and safety check every 10-15 minutes and blood pressure every hour.” The facility submitted a completed LIC624 and submitted it the Department on 5/25/22. LPA finds this portion of the allegation to be Substantiated. 2- On 5/20/21, (R1’s) POA e-mailed the Licensee asking that staff do not place any medication refill orders with a facility-designated pharmacy since they are not a participating pharmacy under (R1’s) insurance plan, and to instead fill all orders immediately with CVS, who is part of (R1’s) PPO Prescription Plan and will mail prescriptions via next-day delivery. One Ombudsman explained there was one time when there was a medication issue and that the facility knew the POA wanted to get (R1's) meds through CVS, but CVS couldn't fill the prescription, but a pharmacy that was nearby could. Resident charting notes dated 5/26/21, state owner, Janet, received an e-mail from the spouse of (R1’s) POA regarding a new antibiotic that was received at the facility the day before from CVS. Notes document “Janet checked with Jenn (Administrator), who checked with all houses and mail, and it had NOT been received” and POA’s spouse was called back to be provided with an update. Another e-mail was sent on Wednesday, 5/26/21, asking Licensee to please confirm if (R1’s) antibiotics were received and if she has started the treatment. The sender asks Licensee to also confirm receipt of medication change orders, faxed on Monday, for medications that are contra-indicative to antibiotics. A follow up e-mail was sent to the Licensee on 6/3/21 asking if the mailer from CVS ever showed up, stating a replacement was ordered and delivered by courier and (R1) is using now. Continued on LIC9099-C Page 4 The Licensee stated that she recalls "one time when (R1’s) POA was adamant the medications were received here but we did not receive them; POA told us the meds were sent but the pharmacy made an error and when one of the staff went to pick up the medications, they were not at the pharmacy”. The Licensee stated she and her spouse, would go to CVS anytime, 24/7, if needed, to get what the residents need. This is substantiated under the allegation pertaining to incoming/outgoing mail not being processed timely. 3- One caregiver was asked if she recalls (R1) missing medications for (3) days due to a UTI and commented "not that I know of". This staff stated if she had heard of this happening, she/staff would report it right away to the lead so a urine analysis could be ordered with a representative obtaining a urine sample within an hour, so the results would be available to the facility by the next morning. One Ombudsman stated that (R1) went (2-3) days without medications because the POA was not willing to have the prescription filled through another pharmacy in the area. LPA finds this portion to be unsubstantiated. Reported as additional information to the allegation, the POA asserts that facility staff “negligently ignored the hospice nurses’ instructions to strictly administer Tylenol for pain” which caused (R1) to show multiple symptoms of “anaphylactic shock (skin pale discolorations, hives, itching, low blood pressure, wheezing and trouble breathing.). The anaphylaxis worsened to the point where (R1) became dizzy and incoherent, and her throat constricted to the point where she had difficulty breathing, and her tongue and throat were swollen to the point where she could no longer eat or drink. She died days later.” The Administrator stated she does not recall any side effects from (R1) being given pain Hydromorphone and indicated that all nurses charted everything very carefully for (R1), and sometimes (2) nurses would be there also to provide care to (R1). The Administrator explained the hospice nurse gave (R1) the first dose and then stayed with her for a few hours to see if there were any adverse reactions, and asserted, "It could very well be that her (R1) tongue was swollen- her body was full of fluid because she was dying- her legs were huge and her body was dying", but (R1) was “cognitively aware until the end”. Continued on LIC9099-C Page 5 The Administrator confirmed, as it is noted on the MAR for June 2022 and July 2022 that (R1) was given Dilaudid, or Hydromorphone, an alternative to morphine that is given to individuals with an allergy to morphine, or in this case, codeine. The MAR for June 2022 reflects that PRN Acetaminophen 500mg (take 2 every 4-6 hours) was administered once daily on 6/24/22, 6/25/22 and on 6/27/22. On 6/29/22, PRN Hydromorphone (Liquid) 1 mg/ml (take 1 ml (1mg) by mouth every 4 hours as needed for pain or shortness of breath) was administered to (R1) once daily on 6/29/22 and 6/30/22. On 6/30/22, the MAR reflects that the prescription for PRN Hydromorphone (Liquid) 1 mg/ml was changed to: “Take 1-2 ml by mouth every 2 hours as needed for pain or shortness of breath” and (2) dosages were given on 6/30/22. On 7/1/22, 7/2/22 and 7/3/22, each day (4) dosages were administered, and (3) dosages were administered each day on 7/4/22 and 7/5/22. On 7/6/22, the prescription for Hydromorphone (Liquid) changed from a PRN to a scheduled medication as follows: Take 2 ml/mg by mouth every (3) hours. The MAR for July 2022 shows this dosage was administered to (R1) starting on 7/6/22 (7:00 am) and was given every 3 hours, with the last dosage given on 7/9/22 (1:00 pm). Resident passed on 7/10/22 at 0029 hours. The cause of death is listed as: Congestive Heart Failure and Atherosclerosis on the county death certificate. Charting notes entered (no date noted) following (R1’s) admission to hospice on 6/20/22 document that the hospice nurse “noted R1 was in so much pain when they were moving her up in bed that she would be discussing pain meds with the POA”. When completing her “Power of Attorney for Health Care”, Section 2.2 Relief from Pain, on 3/21/21, (R1) initialed the option to allow for “treatment for alleviation of pain or discomfort be provided at all times, even if it hastens my death”. (R1’s) Health Care POA become effective on 4/14/22. POA sent a text message on 7/2/22 (3:41 pm) to the lead hospice nurse asking why staff administered Adderall (or Adderol) to (R1) when it was agreed Tylenol would be given first and states that apparently facility staff were authorized to give (R1) Adderall which “knocked her out” and made her “groggy”. MAR documentation for July 2022 (and June 2022) do not reflect any dosages of this medication being given. The hospice nurse was unable to be contacted for an interview due to no longer working for this hospice company. Continued on LIC9099-C Page 6 The Administrator confirmed that facility staff did administer the medication as noted on the MAR documentation and that staff would not have been able to administer any medication without an approved doctor’s order. LPA reviewed staff training records up to the last (3) years for (5) staff who regularly provided care to (R1). Four (4) of five (5) staff worked as both a caregiver and Med-Tech and began their employment at the facility between 2013- March 2021, and at the time of the interviews, Spring 2023, (4) of (5) staff were current employees. All records showed staff had regularly completed multiple trainings on a variety of required and optional topics, through an approved Department vendor, and had current certification in First Aid/CPR. LPA attempted to contact the hospice company and was not able to conduct an interview with a staff person that had worked with the previous lead nurse. Based on the physician changing the medication orders for Hydromorphone (Liquid) from a PRN every (4) hours to every (2) hours, and then to a scheduled medication every (3) hours, it cannot be established that facility staff ignored the nurses’ instructions to only administer Tylenol for pain, and therefore this portion is found to be Unsubstantiated. Allegation: Facility did not contact responsible party in a timely manner. Complaint alleges that resident’s (R1) responsible person was not contacted when resident was sent to the hospital on multiple separate occasions. POA stated he was not contacted to discuss facility concerns on the following days when resident was sent to the hospital emergency room: 11/9/2021, 12/10/2021, 6/8/2022, 6/10/2022 and on 6/17/2022. Email from representative on 6/9/22 to Licensee states he was contacted late last night from the hospital informing him resident went to ER yesterday afternoon, on 6/8/2022, and he was not notified by the facility. The owner stated to LPA "we were not sure who was the POA- (R1) was her own POA", and explained that one time, the other family member was called by accident, and she emailed the POA to explain the error. Continued on LIC9099-C Page 7 LPA reviewed an email, dated 6/9/22, from the Licensee to the POA stating: “The staff on duty had been instructed to call you but they had mistakenly called your (other family member)”. They informed you of this when you called here about 9 pm last night. We are in the process of making the paperwork even clearer that they are to call you.” One caregiver stated "we never call the POA- it is not our place- as a caregiver I report to the lead and the lead will call the ambulance", and explained all staff are trained that 1) a resident's health is most important and to call 9-1-1 first and 2) then call the family, adding "legally when they're in our care, we have to make decisions- the lead calls the family after 9-1-1 is called"- The same staff confirmed there should be a note made in a resident's file when 9-1-1 is called, and most leads are very good at ensuring notes are entered. Charting notes entered on 12/10/21 and 6/8/22 document (R1) was sent out to the hospital; however, they do not indicate that the POA was contacted. The next entry was made on 6/16/22 and documents (R1) was ready to be discharged from the hospital; on 6/17/22, notes indicate that (R1) was sent back to the hospital due to being in “very bad shape and with a very wet cough” and the Administrator called POA to inform him. POA provided email documentation that another family member was notified of (R1) going to the hospital on 6/17/22, and he was not. On 4/22/22, the POA’s attorney sent a letter to the Licensee, along with a copy of a medical evaluation made on 4/14/22 by her primary care physician, determining (R1) to be unable to make her own health care decisions and that (R1’s) POA has POA Medical and is the “agent under the Advance Health Care Directive” for (R1). The letter requests that the Licensee “be sure to alert (POA) regarding any of (R1’s) health care needs, medical appointments, and the like”. Continued on LIC9099-C Page 8 A second family member stated he was never the POA but he "probably talked to the facility half of the time" and spoke to them occasionally, confirming he was "called at least once" when (R1) was sent to the hospital. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Allegation: Facility did not provide 30-day notices prior to moving residents to other rooms in the care home. Complaint alleges that a 30-day notice was not provided to residents when facility moved residents from building 1 to building 2 and only a verbal notice was provided 10-days prior to move, along with a brief notice in writing. NOTE: The allegation should have been written: Facility did not abide by their (60) day notice before moving residents out due to a change in facility use, but because (30) days hadn’t elapsed prior to moving residents, it can still be substantiated, as written. On 5/10/22, the Licensee stated that she notified resident (R1) in person that House #1, where (R1) was living, would be closing by no later than 7/10/22. Email documentation sent on 5/10/22 to the POA (Dec 2020- states that (R1) was notified earlier that day that house #1 would be closing due to Covid-19 and for financial reasons, and the moving process would be started right away. A follow up e-mail was sent the next day, on 5/11/22, to (R1’s) POA stating that that all residents are scheduled to move out of House #1 on 5/19/22 and provided R1’s new mailing address for any moves related to phones, satellite, or newspaper delivery. House #1 operated under a separate license (#455001493) issued by the Department and was located in its own building (1720 COLLYER DRIVE, Redding, CA 96003). House #2 is located at 1750 COLLYER DRIVE Redding, CA 96003, across the street from House #1, and operates under license #455002027. Continued on LIC9099-C Page 9 One care staff stated that many residents passed from Covid in both houses, so all remaining residents were consolidated in House #2. The same staff stated that most residents were very unhappy with the move but (R1) "loved her room- she had a beautiful room with a view of the courtyard with squirrels". Two other staff stated the owners notified resident families of the move and families were able to assist in choosing the new room in House #2. A family member of (R1) indicated he was informed about resident moving to another house, by email, but was not able to confirm if (R1) got to choose her own room in the new house. Licensee provided information to LPA that (R1) “got 2nd choice of rooms since she had been with us the second longest. Hence, there wasn’t any need to wait (60) days since she wanted the room that was the same set up as hers. That was the only room like that”. Licensee stated there was no reason to wait the (60) days since residents were in agreement, and all moving costs and extra staffing were paid for by the facility. Department records document that a follow up inspection was conducted on 8/9/22 at House #1, after the Regional Office received a Notice of Facility Closure with a facility closure date of 05/31/2022, advising thirteen (13) residents, had moved to House #2. Resident (R1) was informed of the move verbally on 5/10/22 and was moved on 5/19/22 from House #1 to House #2, which (R1’s) charting notes confirm. Licensee stated that the “move occurred over one day”. All residents were given approximately (10) days’ notice in advance from when the move took place, on 5/19/22. Licensee stated House #1 and House #2 are on the “same property”, but because they had separate Department Licenses, a (60) day notice was required due to a change in use of the House #1, due to its closing, and not just from a change in resident rooms. Based on information received, LPA finds the allegation to be SUBSTANTIATED- Page 10 Allegation: Facility interfered with resident sending or receiving mail correspondence in a prompt manner. Complaint alleges that resident (R1) had legal mail with a pre-paid priority envelope to her attorney. Resident gave mail to caregiver, who gave it to the house manager, and mail was not sent out for 10 days. Allegation also states that resident had missing packages. The Licensee stated she “remembers one time there were two large envelopes that got delayed” and explained the mailing process is that a caregiver will give any outgoing mail to the Administrator, or a manger, who will mail it on their way home or place it in the mailbox outside the facility. One caregiver recalled (R1) receiving some incoming mail from a lawyer, specifically two large envelopes, and (R1) needed to sign and return it right away. A second staff indicated (R1) would send outgoing mail - stating "she had a lot of important mail to attorneys" and that residents would pass it on to the Administrator as care staff do not handle mailing packages/envelopes. All staff who were interviewed explained that the owners ensure that any outgoing mail is mailed timely, including contacting a staff member or taking the mail to the post office themselves. Staff explained the outgoing mailing process: "we automatically give it to the Administrator, and it gets automatically mailed out” and confirmed there are no internal logs to record mailings. Another staff stated there is a basket to place envelopes or packages in and Mark, the owner, will go to the USPS to mail outgoing mail and pick up incoming mail and will also pick up prescriptions at the pharmacies.” Another staff commented, “normally, in the morning, staff will pick up whatever anyone wants mailed and take it to the mailbox- usually the lead staff would take it out to the mailbox- the kind in a rural area”. A fifth staff said “bosses are pretty good at ensuring mail gets out Mon-Fri but there is no mail that is picked up on Saturdays or Sundays, and staff tells residents that. Continued on LIC9099-C Page 11 Charting notes for (R1) entered on 9/28/21 (Tues) only state “(R1) gave me two big envelopes with a typed return address label to POA on them to mail out”. An e-mail was sent by the POA on 10/1/21 to the Licensee asking for her assistance in locating two pre-paid, USPS Priority Mail envelope mailers that (R1) handed to (staff) Jenny, who promptly delivered them to the Administrator for mailing on Tuesday”. Tracking numbers were provided for both envelopes. The Licensee responded the same day that she or the Administrator “usually take any of the resident’s straight to the post office the day we receive it”, and the Administrator was on vacation, but she would ask her if the envelopes were mailed on Tuesday. The POA followed up by email on 10/5/21 (Tues) asking for an update on when and where the pre-paid mailers were mailed from. The Licensee responded same day they were mailed from the USPS in Anderson, CA. Several more e-mails were sent on 10/6/21 to confirm the day the mailers were mailed with the facility confirming the mailers had been mailed on Wednesday, 9/29/21. The POA indicated the USPS Tracking confirmed the packages were not entered into the USPS tracking system at the Anderson location until 10/8/21 and did not arrive to their destination until 10/10/21, thirteen days after (R1) gave them to the care staff. POA states there were mail-order prescription medications that were confirmed delivered to the facility but were not located. Resident charting notes dated 5/26/21, state owner, Janet, received an e-mail from the spouse of (R1’s) POA regarding a new antibiotic that was received at the facility the day before from CVS. Notes document “Janet checked with Jenn (Administrator), who checked with all houses and mail and it had NOT been received” and POA’s spouse was called back to be provided with an update. Another e-mail was sent on Wednesday, 5/26/21, asking Licensee to please confirm if (R1’s) antibiotics were received and if she has started the treatment. A follow up e-mail was sent to the Licensee on 6/3/21 asking if the mailer from CVS ever showed up, stating a replacement was ordered and delivered by courier and (R1) is using them now. There were no notes entered as to if the original mailer was received. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED. The above (4) allegations have been found to be SUBSTANTIATED- finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (4) citations are issued on the 9099-D pages. An exit interview was conducted and a copy of the report and appeal rights were provided. Report was prepared by LPA Sabrina Calzada. LPA Rebecca Knight presented the report to the administrator this date. Page A1 A second care staff stated that in 2021, "staffing was consistent and all staff worked on the same day and had a set schedule"; in 2022, staffing was "all over the place" but they had the same staff helping (R1) to ensure she was provided with consistent care the same way. A third caregiver indicated that staff would work a double shift and use a temporary help agency to ensure there was enough staffing. A fourth care staff stated, "there were no issues- (R1) would always get assistance when she rang the bell"; she might have to wait 15 minutes at times, asserting, "she always got care". A fifth caregiver explained there were usually (3) caregivers for (20) residents and when asked if the facility was ever understaffed, replied, "in general, maybe" and “this was an issue for all facilities at this time.” One Ombudsman stated, “Lavender Hills has done very well with staffing- they've done a really nice job and tend to attract more staff due to being a higher end facility.” A family member was asked if he ever observed insufficient staffing and stated "No, whenever I saw (R1), staff attended to her- it was my impression that staff was doing a good job" and further commented, "they were probably short-staffed, but she got the care she needed". LPA reviewed an email from the Licensee to (R1’s) POA on 3/4/22 discussing staff concerns that (R1) refused physical therapy and a shower. Licensee states she asked (R1) about her complaint that staff members take 30 minutes to provide assistance when requested, and (R1) told her she doesn’t have to wait that long and staff always attend to her right away and take very good care of her. Licensee states to POA in the email that it is “important she gets a shower as we need to make sure she is clean and skin breakdown isn’t happening”. Email sent on 3/3/22 from the Licensee states she investigated POA’s claim about staff taking 30 minutes to provide care and staff have complained that (R1) has at times pushed her button excessively, and when they get to her room, it’s only actually been 5 minutes, as staff timed it, and not 30 minutes as (R1) may have said. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED. Continued on LIC9099-C Page A2 Allegation: Staff are not assisting residents with ADL’s. Complaint alleges (R1) did not receive assistance with meals, showers, and incontinence care. Licensee confirmed staff aided with meals, showers and incontinent care. Licensee stated “(R1) didn't want to get up to use the toilet, especially towards the end. LPA reviewed an e-mail sent from (R1’s) POA, on 3/3/22, regarding excessive delays (15 mins) in staff responding to (R1) - possibly due to Covid situation. Licensee promptly responded that (R1) is declining, will push the call button excessively, forgets she called for assistance, will be asked if she needs anything prior to staff giving another resident a bath, but then will soon after call staff for assistance, just after staff started to shower another resident. The Licensee declared "(R1) would refuse to come to the dining room and staff would take a tray then", commenting staff provide "individual care' and "(R1) got the best care due to the staff’s love for her- they went above and beyond". One caregiver stated that (R1) "ate good and she asked for help in pushing her wheelchair to the dining room", explaining "some days she preferred to use the wheelchair and not walk" and (R1) did not have a special diet and sometimes would eat in her room. A second caregiver indicated that (R1) was "self-sufficient and was a good eater" and sometimes staff would cut her food if she asked, and (R1) often asked for extra glasses with beverages. A third caregiver conveyed that staff would cut up (R1’s) food only and (R1) could use the utensils herself. All staff interviewed stated they assisted (R1) with showers, including helping her walk to the shower, undress and dress afterwards. When asked if (R1) ever refused a shower, one staff exclaimed, "never for me" and confirmed resident was scheduled for (3) showers per week in the mornings. Another caregiver stated that hospice would give showers (2-3) times/week and she and other staff would fill-in on other days and give a bed bath, commenting, "(R1) very rarely would refuse a shower when I was on shift, explaining she sometimes filled in on the morning shift. Licensee stated “(R1) would refuse showers, but we would try a change of face and she would prefer a bed bath a lot". One staff stated that staff will document in a book if a resident refuses a shower. Concinued on LIC9099-C Page A3 Regarding toileting and incontinent care, one staff stated "(R1) had a lot of accidents and we did (5-6) loads of laundry on the "pm" shift", explaining there were (2) pads on the recliner chair and (R1) was constantly taking off her Depends (diaper) and throwing it on the floor along with the chair pads, and then the chair would get soaked with urine. This staff stated (R1) needed more assistance the last two years as she had early stages of Dementia. Another caregiver stated (R1) wouldn't always ring the bell after soiling her diaper and "for the most part, she was able to toilet herself- sometimes she needed help getting up from the toilet or commode". A third staff remarked "residents are always taken care of- they still get pottied but may have to wait a few minutes". When asked if there were any issues with (R1) not receiving assistance with meals, showers, incontinent care and other ADL’s, a staff of many years stated "no, we were always there" to help and confirmed that (R1) knew how to use her necklace pendant. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED. Allegation: Facility did not treat resident with dignity. Complaint alleges that 1- POA reported to the Licensee that an unknown staff member told resident that she smelled bad. 2- Also, when Administrator found out resident wanted to move out of facility, she entered resident's room to discuss regardless of resident declining to talk. 1- E-mail documentation from resident’s POA on 4/1222 informed the Licensee that (R1) called the POA the night before and was upset about a staff telling her she “smells bad” and was told this by several staff over the past several weeks also. The Licensee replied on 4/12/22 that she followed up with all staff involved and no staff have told (R1) she smells bad, but (R1) has “on occasion told staff she smells bad, and they tell her they will take care of it right away”. Licensee stated (R1) told her “No one has said anything mean to her, and the staff has always been so attentive and kind to her”. Continued on LIC9099-C Page A4 Licensee stated that (R1) is aware the smell is coming from her chair, not her, as she continues to urinate in it, possibly due to her medications, and that “cleaning the chair did not fix the problem. It wasn’t a day later, and it was already soaked again”. Licensee explained that even though there are always (2-3) chucks under (R1), and “the staff clean her and everything after every episode, it does not solve the soaking of the chair, which she is in 24 hours a day, 7 days a week”. The Licensee expressed she was receiving daily complaints from both staff and residents; however, was clear that “the odor was not from (R1) but from the chair”. One care staff explained "many times" (R1) wouldn't wear the Depend (diaper) at night because it was "very soiled", and she would hang it on her walker, and several residents would comment while walking in the hallway near (R1's) room that it "smelled like cats" because of the urine smell coming from the room. This staff stated that (R1) "might have heard residents saying the area outside her room smelled, but it was never said to her face", and explained that the door to (R1’s) room was opened the majority of the time, and the back of her recliner was facing the hallway, and "(R1) couldn't see who said what". This staff asserted "I personally heard (2-3) residents comment about the smell" and (R1) would never questioned staff when they would constantly spray Febreze or Lysol in the hallway or in her room, due to the urine smell. This staff asserted that she never heard a staff member say that (R1) smelled and commented "(R1) probably heard residents say it smelled "right in this area" just outside her room". Another staff indicated she is not aware of (R1) ever being told she "smelled bad' and stated, "I did tell her a couple of times- Let's get you in the shower before you start to stink". This staff explained that (R1) would often refuse showers before she went on hospice and so staff would tell he she needed a shower. LPA finds this portion of the allegation to be unsubstantiated. 2- Licensee and Administrator asked to speak to (R1) in her room on 6/17/21, in the presence of (R1’s) POA and spouse, and during the conversation, the Licensee stated, “we think you’d be happier living elsewhere”. Resident’s POA stated this was perceived as abusive and caused (R1) to be emotional and have perceptions of depression following the incident. Continued on LIC9099-C Page A5 Charting notes entered on 6/17/21 document the reason the Licensee and Administrator went to (R1’s) room was to follow up about a conversation a staff member heard the day before, Wednesday, between (R1) and the POA about (R1) ringing her button every 5 minutes and to note the names of staff who do not respond quickly enough. (R1) indicated she remembered the conversation and proceeded to tell the Licensee they were indeed “looking at other facilities” due to everything that has been going on. The notes say the Licensee responded, “that is probably a good idea at this point” and clarified, “we just want her happy, and I think this is causing a lot of stress on her”. Notes say (R1) commented, “This is very stressful and if you guys think it’s a good move, we’ll just make it and we’ll all be peaceful.” The notes do not say that indicate that (R1) declined or did not want to speak to the Licensee and Administrator. LPA finds this portion of the allegation to also be unsubstantiated. Based on information obtained, LPA finds the above (3) allegations to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of the report was provided. Report was prepared by LPA Sabrina Calzada. LPA Rebecca Knight presented the report to the administrator this date. Page C2 Charting notes from 6/8/22 state (R1) was sent to the hospital emergency room (ER) for being “weak and not feeling well” and was admitted for influenza. Resident’s notes, dated 6/16/22, state the hospital was ready to discharge (R1) and recommended doing so under hospice care which (R1) “qualified for and needed”. Licensee stated to (R1’s) POA that an assessment would have to be done prior to (R1) returning to the facility to ensure staff could meet her care needs. These notes say that (R1’s) POA didn’t wish for an assessment to be done and then agreed to have (R1) return on hospice so the facility would have the “tools and help to care for her, which the hospital agreed she qualified for and needed”. (R1) returned to the facility later that evening and met with hospice care personnel at which time resident’s POA changed his mind refused the hospice care. Charting notes document that (R1) was sent back to the hospital on 6/17/22 for very low oxygen levels (86) and being in “very bad shape with a very wet cough”. The notes say (R1’s) POA was contacted and informed the reason resident had to be sent out again was because she was not under hospice care. Charting notes from 6/20/22 note that (R1) began hospice services that day. On 6/18/22, the Licensee e-mail a request that (R1’s) POA complete the attached hospice forms so resident could return to the community the next day. LPA reviewed the POA’s e-mail response sent on 6/19/22, which included the signed documentation for initiation of hospice services and asks about (R1) starting on Palliative care instead, as discussed with the attending physician at the hospital. Licensee promptly responded that for “the care home to properly care for (R1), she needs to be under hospice care, explaining the better access to nurses and doctors and the option to also graduate from hospice care if it’s no longer needed”. The Admission Agreement (page 5, item 7) addresses the facility having a hospice care waiver in place and mentions a one-time fee that is charged “if and when Hospice Services are required”. Continued on LIC9099-C Page C3 One Ombudsman stated to LPA that if (R1) has low oxygen, the facility needs to send her to the ER since they are non-medical, asserting “(R1) was sent to the ER due to oxygen levels lower than 70, and the facility told the hospital that (R1) needs Oxygen to return or needs to be on hospice.” The Ombudsman stated (R1’s) POA was fine with hospice until finding out (R1’s) assigned primary care physician would be different and she worked with the facility and the hospital to try and work out the situation, and finally (R1) was placed on hospice. Resident passed on 7/10/22. A second family member stated he would visit (R1) 5-6 times/year and on one visit, owner, Janet, told him in person it is best that (R1) begin hospice services. The Administrator stated, "we didn't say she (R1) couldn't come back unless she was on hospice" and asserted “(R1) was gasping for air in the hospital, and her vitals were not stable- her heart was failing, and her legs were full of fluid". Based on information obtained, LPA finds the allegation to be UNFOUNDED- meaning that the allegations were false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of the report was provided. Report was prepared by LPA Sabrina Calzada. LPA Rebecca Knight presented the report to the administrator this date.the state’s words, verbatim · CDSS document, Sep 5, 2023 · control 25-AS-20221227141203

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a))4) · Plan of correction due date: Sep 20, 2023

87465(a)(4) Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on documentation review, the Licensee did not ensure that (R1) received medications as ordered on 5/25/22, when (R1) received (2) medications,50 mg. Pregabalin and 25 mg. Hydralazine, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 5, 2023

Plan of correction: Licensee / Administrator agrees to conduct training with all caregivers on the requirements for assisting residents with self-administered medications. LIcensee shall submit the training materials and staff sign in sheet to LPA Calzada as proof of correction by 9/20/2023.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 9746(8)(1) · Plan of correction due date: Sep 20, 2023

87468.1 Personal Rights (a)(8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs.This requirement was not met as evidenced by: Based on interviews conducted and documentation reviewed, the Licensee did not ensure that resident’s (R1’s) representative/POA was contacted when (R1) was sent to the ER on multiple times between, November 2021- June 2022, which posed a health and safety risk and/or personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Sep 5, 2023

Plan of correction: Licensee / Administrator agrees to conduct training with all caregivers on the requirements to notify resident's representative / POA when a resident is sent to the ER. LIcensee shall submit the training materials and staff sign in sheet to LPA Calzada as proof of correction by 9/20/2023.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87724 · Plan of correction due date: Sep 20, 2023

87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5) Change of use of the facility. (A) The licensee may, upon no less than sixty (60) days written notice, evict a resident due to change of use of the facility. (1) In addition to written notice to quit requirements specified in Section 87224(d), written notice to evict due to change of use of the facility shall be made to the resident or the resident’s responsible person and shall include all requirements specified in Section 1569.682(a)(2)(A) through (F) of the Health and Safety Code. This requirement was not met as evidenced by: Based on documentation reviewed, the Licensee did not ensure that they abided by their (60) day notice issued on 5/10/22, and not move residents (and R1) from House #1 to House #2, until on/around 7/10/22, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 5, 2023

Plan of correction: Licensee agrees to review the requirements for eviction procedures and submit a statement of understanding. LIcensee shall submit the statement of understanding in writing to LPA Calzada as proof of correction by 9/20/2023.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(15) · Plan of correction due date: Sep 20, 2023

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (15) To send and receive unopened correspondence in a prompt manner. This requirement was not met as evidenced by: Based on interviews conducted and documentation reviewed, the Licensee did not ensure that (R1)’s incoming and outgoing mail was processed timely in May 2021 and September 2021, which posed a personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Sep 5, 2023

Plan of correction: Licensee agrees to establish a process to ensure all outgoing mail is mailed timely and incoming mail is delivered to residents timely. LIcensee shall submit the process in writing to LPA Calzada as proof of correction by 9/20/2023.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Ivan Avila and Kerry Hiratsuka arrived at the facility unannounced on 4/13/23 to conduct a Annual Inspection. LPAs met with Administrative Assistant Naitasha Peerman and were met later in the visit with Jennifer Boss and explained the purpose of the visit. LPAs toured the interior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, 5 resident bedrooms, bathroom, kitchen, and medication room. LPAs observed the facility to be clean, in good repair and odor-free and each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels, trash can with lids and 20-second hand-washing poster. LPAs observed sufficient 2+day perishable and 7+day non-perishable supply of food and sharps to be locked. In the areas toured no immediate health, safety, or personal rights violations were observed. Resident care needs appear to be met. LPAs compared ordered medication to medication being given for 1 client and found no discrepancies. LPAs reviewed 3 staff files and found them to contain current First Aid and training. And review 3 resident files. Several topics discussed. No deficiencies are being cited. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Apr 13, 2023

Allegation investigated: Illegal eviction. Personal rights.

/25/2022 Licensing Program Analyst (LPA) Shannon Diegoruelas, arrived at the facility unannounced to deliver findings for a complaint investigation for the above allegations. LPA met with Naitasha Peerman, Administrative Assistant and explained the purpose of the visit. Prior to initiating the visit, LPA completed required COVID-19 daily self-screening for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA contacted facility and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical mask. Additionally, LPA was screened by facility staff. Continued 9099-C Unfounded Illegal eviction. Personal rights. It has been determined regarding the above allegations from record review and through correspondence from facility, the facility communicated with R1's authorized representative in a timely and appropriate manner and provided R1 every reasonable opportunity to return to the facility from the hospital. Facility stated they never refused to take R1 back or issued any form of eviction, on 06/16/2022 the authorized representative was simply made aware, that due to R1’s rapidly declining condition at the hospital, and facility being non-medical, that R1 would either have to be stabilized at a rehabilitation facility or return to facility on hospice, as the hospital already said R1 qualified. Authorized representative agreed to hospice and then later declined after R1 was already back at the facility. On 06/17/2022 because R1 was not on hospice R1 had to be sent back to Mercy ER for low O2. Then on 6/20/2022 R1 was signed onto hospice by authorized representative and R1 returned to the facility. Based on records reviewed to support facility's statement: -Facility's documentation for R1 from 06/16/2022, 06/17/2022, and 6/20/2022 that coincide with facility's statement. -Mercy ER's admission and discharge orders for R1 confirmed with the dates the facility stated. The department has determined that the complaint alleging an illegal eviction and personal rights violation was UNFOUNDED meaning that the allegations were false, could not have happened and/or is without a reasonable basis. No citations are being issued as a result of today's visit. Exit interview was conducted and a copy of report was provided to Administrator.the state’s words, verbatim · CDSS document, Oct 25, 2022 · control 25-AS-20220617135448

Type of visit: Required - 1 Year

3/08/2022 2:00 p.m Licensing Program Analyst (LPA) Dawn Keane and Misty Valencia, arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Jennifer Boss, Administrator (AD) and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA contacted AD and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical mask. Additionally, LPA Keane and Valencia were screened by AD/staff person. LPA Keane, Valencia and the AD toured facility to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, two (2) bathrooms, three (3) bedrooms, kitchen, storage areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA Keane and the AD completed the infection control domain and facility was found to be in substantial compliance at this time. No deficiencies are being cited as a result of today’s inspection. Exit interview conducted and copy of report was given to AD.the state’s words, verbatim · CDSS document, Mar 8, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) K. Hiratsuka, arrived at the facility unannounced on 07/08/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Administrator Jennifer Boss, and explained the purpose of the visit. Prior to initiating the annual inspection visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Facility Representative and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by the Caregiver. LPA and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, common restrooms, and laundry room. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Administrator completed the infection control domain and facility was found to be in substantial compliance at this time. LPA did this visit concurrently with LAVENDER HILLS ASSISTED LIVING III 455002615, and LAVENDER HILLS ASSISTED LIVING LLC 455001493. No deficiencies are being cited as a result of todays inspection. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Jul 8, 2021