Sunshine Health Place 2

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Case Management - Annual Continuation at the facility today continuing the inspection that began on 05/23/2023. The LPA met with staff at 2:32 PM and explained the reason for the inspection. The Administrator was contacted an informed of the inspection. Administrator Cilva Toume arrived during the inspection. During today's inspection the LPA conducted a physical plant tour and reviewed facility records. The LPA reviewed records for five residents. Files were reviewed for but not limited to admission agreements, medical assessment, needs and service plans, and physician orders. Resident #1 (R1) has a diagnosis of dementia and has a medical assessment older than one year (2/18/2022). Resident #2 (R2) has a needs and service plan older than one year on file (05/09/2021). Files were otherwise complete. The LPA reviewed four staff files for but not limited to, criminal record clearance, personnel records, physicals, and training records. Files reviewed were complete. During the physical plant inspection, the LPA observed all five residents had half bed rails. One out of the five residents did not have a physician order on file for the rails. Pursuant to the California Code of Regulations, Title 22, Division 6, the following deficiencies was observed and cited during the visit. See LIC 809-D. Exit Interview conducted and the report was reviewed with the Silva Toume. Appeal Rights and a copy of this report has been issued.the state’s words, verbatim · CDSS document, Jun 30, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Required 1 Year Inspection at the facility today. When the LPA arrived there were two staff and five residents present. Licensee Representative Cilva Toume was contacted at 2:35 PM and advised of the visit. Ms. Toume arrived shortly after the inspection began. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN: The kitchen and food storage areas were observed. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food stored in the kitchen and in the garage. Knives were secured in a locked box. During the inspection, the LPA observed dishwasher cleaning pods in an unlocked cabinet underneath the kitchen sink. The LPA also observed cleaning supplies and disinfectants in an unlocked garage and Ajax cleaner in a cabinet with a lock that was not working properly in the restroom near bedroom 6 and bedroom 7. COMMON SPACES: In the common areas, furniture, walls, and flooring were clean and in good condition at the time of the inspection. All indoor and outdoor passages were free of obstruction. The fire extinguisher was fully charged and last purchased on 12/05/2022. At 3:07 PM, the carbon monoxide detector and smoke detectors in the common areas and bedrooms were tested and were operational. Medications are centrally stored in a locked closet in the hallway. Medications were reviewed and were observed to be be administered as prescribed and recorded on the centrally stored medication records. The backyard has covered outdoor seating for resident use. BEDROOMS: There are seven resident bedrooms and one staff bedroom. The LPA observed the resident bedrooms to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Due to time constraints, the LPA needs to return at a later date to continue the inspection. Pursuant to the California Code of Regulations, Title 22, Division 6, the following deficiencies was observed and cited during the visit. See LIC 809-D. Exit Interview conducted and the report was reviewed with the Silva Toume. Appeal Rights and a copy of this report has been issued.the state’s words, verbatim · CDSS document, May 19, 2023

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Facility is operating outside of license terms and conditions Resident is not provided comfortable accommodations at the facility

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct an initial 10 day visit. The LPA met with Administrator Cilva Toume and explained the reason for the visit. Today, the LPA conducted a tour of the facility at 9:37 a.m., interviewed staff at 9:45 a.m., 10:10 a.m., and 10:17 a.m., and interviewed residents at 9:47 a.m., 10:00 a.m., and between 11:30 a.m. – 11:40 a.m. Regarding the allegation: Facility is operating outside of license terms and conditions It was alleged that the facility was operating outside of the license terms, as it was alleged that the facility had housed seven (7) residents. Interviews and records review confirmed that the morning of 11/30/2022, there were four (4) residents that resided at the facility. Substantiated Interviews with the Administrator confirmed that, due to emergency circumstances of another facility closing, the Administrator accepted three (3) residents the afternoon of 11/30/2022. Records review confirmed that there were seven (7) residents from 11/30/2022 – 12/02/2022. The Administrator alleged that one (1) out of seven (7) residents was supposed to move out on 11/30/2022, however, the resident in question moved out on 12/02/2022. Whereas at this time, there are currently six (6) residents residing at this facility, there is sufficient evidence to support the claim that the facility operated outside of its licensing terms and conditions from 11/30/2022 – 12/02/2022. This allegation is deemed Substantiated at this time. Regarding the allegation: Resident is not provided comfortable accommodations at the facility It was alleged that the facility failed to provide comfortable accommodations to the residents of this facility. During the physical plant tour, the LPA inspected the furniture and equipment used by the residents and observed it to be in operable condition. Interviews confirmed that the staff attempted to meet all specifications and accommodations of residents in the facility to the best of their ability. The Administrator confirmed that there was a former resident that requested an electric bed and whereas the Administrator thought they had the bed as specified by the resident, it did not fully meet the resident’s expectations. As a result, the resident purchased their own electric bed. There was also a concern raised as it alleged that the facility showers cannot accommodate residents with wheelchairs. The Administrator claimed that they had not had an issue with the residents showering in the facility and said that they were able to provide shower chairs and staff could assist those that required hands-on assistance with showering. Resident interviews confirmed that there was one resident that believed the bathrooms could not accommodate their needs as it did not allow their wheelchair to go in; whereas they were able to eventually shower, it was noted that the water appeared to be hot. The LPA observed that one (1) of three (3) restrooms required a lot of maneuvering if a resident wanted to take a shower with their wheelchair. However, a resident could be assisted to the shower chair in that bathroom if need be. The LPA observed that two (2) out of three (3) bathrooms would require a resident to be moved to a shower chair, or would require assistance for their wheelchair to be maneuvered into the shower. As such, the facility would be able to meet showering needs as requested. However during today’s visit, the LPA tested the water in the two (2) common hallway bathrooms. At 10:25 a.m., the LPA tested the water in the 1st common hallway bathroom, and the water measured at 125.7 degrees Fahrenheit. At 10:37a.m., the LPA tested the water in the 2nd common hallway bathroom and the water measured at 124.3 degrees Fahrenheit. Based on the information obtained in interviews and observations, the staff attempted to meet resident accommodations as required in the resident’s medical assessment, or at the request of the resident. However, the facility failed to provide comfortable accommodations for all residents, as the water temperature measured between 124.3 – 125.7 degrees Fahrenheit. This allegation is deemed Substantiated at this time. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D). Civil penalty assessed. Exit interview conducted, today's report and appeal rights were reviewed and issued. Signatures were obtained. Staff said they took claims of observing roaches or any pests seriously. Residents denied claims that they had seen any roaches or pests throughout the day. The LPA inspected the facility thoroughly, including the three (3) facility bathrooms, and did not observe any roaches or pests at the time of the visit. Based on the information obtained from interviews, there is insufficient evidence to support the claim that the staff are not addressing the roach infestation at the facility. At the mention of bugs being observed, the staff purchased bug spray and acted accordingly. Staff denied claims of seeing any roaches in the facility throughout the day and said that there wasn’t an apparent infestation. Based on the information obtained, this allegation is deemed Unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Dec 5, 2022 · control 29-AS-20221202113756

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87204(a) · Plan of correction due date: Dec 6, 2022

87204(a) Limitations-Capacity and Ambulatory Status. A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above, as the facility had seven (7) residents between 11/30/22-12/2/2022 when they are licensed for a maximum of six (6) residents, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 5, 2022

Plan of correction: The Administrator agreed to do the following: 1. At this time, there are only six (6) residents. Review regulation 87204 and communicate how the facility will maintain voluntary compliance. Submit Statement of Understanding by 12/06/2022. Zero tolerance violation; civil penalty in the amount of $500 is assessed.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Dec 5, 2022

87303(e)(2) Maintenance and Operation. Hot water temperature controls shall be maintained ... attain a temperature of not less than 105 degree F and not more than 120 degree F. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above, as the water temperature measured between 124.3 – 125.7 degrees F, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 5, 2022

Plan of correction: The Administrator agreed to do the following: 1. Adjust the water tank within the next 24 hours 2. After adjusting the water, keep a five day temperature log and submit to CCL within the next seven days.

Allegation investigated: Staff are not meeting the resident's incontinence needs Staff are not changing residents bandage timely Staff are not following physicians orders

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for a subsequent visit to deliver findings. The Administrator Cilva Toume arrived at 10:25 a.m. and the LPA explained the reason for the visit. During the initial visit on 7/29/2022, the LPA interviewed staff at 9:15 a.m., and 9:27 a.m., interviewed residents at 9:35 a.m., 10:15 a.m., 10:20 a.m., and 10:25 a.m.; and interviewed a home health nurse at 11:50 a.m. The LPA collected pertinent documents and conducted a tour. On 8/2/2022, the LPA interviewed staff at 9:33 a.m., 9:40 a.m., and 10:15 a.m., interviewed a resident at 9:25 a.m., and observed staff administer care to Resident #1 at 9:30 a.m. Home health records were requested and reviewed. CONT 9099-C Substantiated Regarding the allegation: Staff are not meeting the resident's incontinence needs It was alleged that staff were double diapering Resident #1 (R1). Staff interviews confirmed that staff would place two pull-ups on R1 because of R1’s bowel and bladder incontinence. During the initial visit on 7/29/2022, the LPA was informed that R1 had on two pull-ups; at the time of observation, staff reiterated that they did so due to R1’s incontinence. At the time of observation, a home health representative was providing care to R1, and the home health representative informed staff that R1 only needed one pull-up, required frequent changing, and educated staff on the concern of skin breakdown if R1 sits in a moist pull-up for an extended period of time. An interview with a home health representative communicated that R1 was at higher risk for skin breakdown with the usage of two pull-ups and required frequent changing. Besides the observed dates of 7/29/2022, a review of home health notes indicated that R1 was observed wearing two pull ups on the following dates: 5/31/2022, 6/7/2022, 7/5/2022, and 7/21/2022. Based on the information obtained from interviews, observations, and records review, there is sufficient evidence to support the claim that staff are not meeting the resident's incontinence needs. This allegation is deemed Substantiated at this time. Regarding the allegation: Staff are not changing residents bandage timely It was alleged that staff were not changing R1’s bandage on their left leg in a timely fashion. Records and interview indicated that R1 developed a blood blister on the left leg on approximately 7/7/2022. A review of home health records documented an order for the dressing on the wound to be changed every 2-3 days, or as needed, if the wound dressing becomes soiled. Records indicated that during a home health visit on 7/12/2022, R1’s bandage on the left leg was changed. Home health had educated the staff on the care for the left leg wound and communicated that the bandage would need to be changed every 2-3 days or if the bandage became soiled. Home health returned to the facility on 7/21/2022 and observed that the dressing in place on the left leg wound was dated 7/12/2022. Staff informed the home health representative that they had not changed the dressing as they assumed that the home health nurse was going to do so. As a result, the wound dressing had not been changed for nine (9) days. At the time of observation on 7/21/2022, the wound dressing was soiled. Thereafter, nursing visits from home health were increased to ensure the bandage was changed regularly. Staff interviews confirmed that at that time, home health nurses were changing the bandage on R1’s left leg wound every other day. Based on information obtained from interviews and record review, there is sufficient evidence to support the claim that staff did not change R1’s bandage timely. This allegation is deemed Substantiated at this time. Regarding the allegation: Staff are not following physician’s orders It was alleged that staff were not following the physician’s orders from home health related to wound care. Records review indicated that R1 developed a stage 2 pressure injury on the buttocks on approximately 5/12/2022. Interview with home health staff revealed that it was suspected that the wound developed due to poor incontinence care, not repositioning R1 timely, and utilizing two pull-ups on R1. At that time, staff were instructed to keep R1 dry, to change R1 frequently, and to apply barrier cream. Staff interviews confirmed that they provide barrier cream to R1’s buttocks timely, ensure that R1 is repositioned, and ensure that R1 is dry. A review of home health notes indicated that R1 was observed wearing two-pull ups on 5/31/2022, 6/7/2022, 7/5/2022, and 7/21/2022. During the visit conducted on 7/29/2022, LPA observed that R1 had on two pull-ups. Staff claimed that they used two pull-ups due to R1’s incontinence, yet according to home health, wearing two pull-ups can also aid in skin breakdown. A review of home health notes regarding R1’s wound on the buttocks indicated that on the following dates, the barrier cream was observed to be applied either incorrectly or minimally: 5/31/2022, 7/25/2022, 7/27/2022, and 7/29/2022. Lastly, whereas there was an order to change R1s’ bandage on the left leg wound every 2-3 days or as needed if soiled, staff did not change R1’s between 7/12/2022 – 7/21/2022, as staff assumed that the home health nurse would change the wound dressing. Based on the information obtained from interviews and record review, there is sufficient evidence to support the claim that staff are not following physician’s orders. This allegation is deemed Substantiated at this time. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D). Exit interview conducted, today's report and appeal rights were reviewed and issued. Signatures were obtained.the state’s words, verbatim · CDSS document, Nov 1, 2022 · control 29-AS-20220722130110

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87625(b)(1) · Plan of correction due date: Nov 3, 2022

87625(b)(1) Managed Incontinence. …The licensee shall be responsible for the following: (1) Ensuring that residents who can benefit from scheduled toileting are assisted or reminded to go to the bathroom at regular intervals rather than being diapered. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above, as R1 was double diapered due to their bladder and bowel incontinence, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 1, 2022

Plan of correction: The Administrator agreed to do the following: 1. Submit a Plan of Action, indicating how staff will care for residents with bladder and bowel incontinence. Submit plan of action no later than 11/3/2022. 2. Hold an in-service training with all staff regarding regulation 87625 Managed Incontinence. Submit sign-in sheet of completed training within the next seven days, but no later than 11/8/2022.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Nov 3, 2022

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. …Residents … shall have ...the following ... rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency... This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above, as staff failed to follow physician’s orders related to wound care for R1, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 1, 2022

Plan of correction: The Administrator agreed to do the following: 1. Submit a Plan of Action, indicating how staff will care for residents with bladder and bowel incontinence, as well as those with wounds. Submit plan of action no later than 11/3/2022.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ashley Smith arrived at the facility unannounced to conduct a required annual visit at 10:10 a.m. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Cilva Toume and explained the reason for the visit. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: Knives are stored in a locked cabinet in the kitchen. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS: The LPA observed the single-room bedrooms, which were furnished appropriately with clean linens, furnishings and sufficient lighting. RESTROOMS: Restrooms are clean, sanitary and in operating condition with grab bars and non-skid surfaces. The LPA observed appropriate hand-washing signs in the restrooms. COMMON SPACES: Walls and flooring were checked for cleanliness and good condition. Passageways were clean and clear of obstructions. No bodies of water were noted in the backyard. The LPA observed all the required postings in the dining room and the hallway that promoted cough etiquette, signs and symptoms of COVID-19, and appropriate hand hygiene. Medications are kept locked inaccessible in the hallway cabinet. Hand sanitizer was available for staff and resident use. The LPA observed that the Department Provider information Notices (PINs) were posted on a board in the kitchen. INFECTION CONTROL: The facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE). The facility’s cleaning protocol is sufficient. The facility can designate a single isolation room if the facility has a confirmed case of COVID-19. The Administrator continues to conduct testing, regardless of vaccination status. The facility’s policies and procedures as it pertains to infection control are adequate. No deficiencies cited at this time. Exit interview conducted. Signatures obtained.the state’s words, verbatim · CDSS document, May 10, 2022