Mountain Ridge Senior Care

Allegation investigated: Staff mismanaged residents' medications

On 04/07/23 at 12:15PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with administrator (ADM), conducted interviews and record reviews and delivered investigation finding to ADM. LPA explained the purpose of the visit with administrator. Allegation: Staff mismanaged residents' medications Investigation Finding: SUBSTANTIATED During visit, ADM confirmed with LPA that she pre-poured residents (R1, R2, R3, R4) medications in different containers from their prescribed storage bottles/bubble packs because she will be away for a few days. On 03/30/23, witness (W1) also observed residents’ medications stored in different containers from their original prescription bottles/bubble packs. Continued on next page, LIC 9099-C Substantiated Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff mismanaged residents’ medication was found to be substantiated. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 7, 2023 · control 15-AS-20230405092226

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(5) · Plan of correction due date: Apr 28, 2023

The following requirements shall apply to medications which are centrally stored: Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement was not met as evidenced by staff mismanaging residents' medications which posed a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 7, 2023

Plan of correction: By POC due date, Administrator agreed to complete and submit to CCLD in-service staff retraining certification on proper medication administration to ensure compliance with Title 22 Section 87465 (h) (5).

Type of visit: Required - 1 Year

On 02/22/23 at 12:05PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct infection control inspection. LPA met with administrator and explained the purpose of the visit. LPA observed 2 staff wearing face masks and 4 residents eating lunch. LPA toured the facility including but not limited to the front entrance, screening station, hand washing stations, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, clients and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizer were observed at the screening station. Cough/sneeze etiquette, social distancing signs were posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs maintained at a central location and easily accessible for staff. Comfortable temperature is maintained at 75 deg F. Facility has a mitigation plan in place and maintains records of routine screening for clients and staff. The infection control leader is the administrator. Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 02/23/23: · LIC500- Personnel Report · LIC308- Designation of Facility Responsibility · LIC610E- Emergency/Disaster Plan including infection control plans · Evidence of Liability Insurance No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 22, 2023

Type of visit: Required - 1 Year

On 02/17/22 at 1:40PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an infection control annual inspection and explained the purpose of the visit with administrator. LPA observed 2 staff wearing face masks during visit with 4 residents watching TV in the living room. Facility has a completed mitigation plan in place dated 04/21/2021 to mitigate the spread of COVID-19. LPA discussed the completed mitigation plan (LIC 808) with administrator as well as COVID-19 infection control practices. LPA inspected the facility inside and outside. LPA observed screening station located near the front entrance with visitor's log, hand sanitizer, gloves, face masks and no touch temperature probe. Routine symptom screening (+/-) temperature and symptom check) is done at entry for all staff, residents and visitors. LPA observed COVID-19 signages posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. Facility documents daily temperatures and COVID-19 symptom checks for staff and residents. Pathways were observed to be free of obstruction and fire hazards. Continued on next page LIC 809-C A written Emergency/Disaster plan dated 01/01/2022 was posted in the kitchen area. Centrally stored medications were locked in the steel cabinets next to the hallway. Sharp objects were locked in a locked cabinet in the laundry room. Toxic chemicals were locked in the laundry room. Administrator stated they have a portable PPE cart available for use outside the designated isolation room with hand sanitizer, gowns, face shield, gloves and masks. Facility has conducted staff training on infection prevention, symptoms, transmission and proper donning & doffing of PPE. Trash bins with lid operated with foot pedal were located inside bedrooms, bathrooms and kitchen. Infection control designated leader is the administrator. All staff and residents have been fully vaccinated since February 2021 and boosted October 2021. There was at least 7 days of nonperishable and 2 days of perishable foods. Emergency food supplies were observed stored in the garage. Facility room temperature was maintained at 72 degrees Fahrenheit. Administrator is on site a minimum of 20 hours a week to oversee proper business operation and compliance with COVID-19 infection control practices. Fire extinguisher was observed fully charged. Smoke and carbon monoxide detectors were operational. Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 02/18/22: · LIC500- Personnel Report · LIC308- Designation of Facility Responsibility · LIC610E- Emergency/Disaster Plan · Evidence of Liability Insurance No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided to administrator.the state’s words, verbatim · CDSS document, Feb 17, 2022