Cordial Care Home

Type of visit: Case Management - Annual Continuation

On 08/24/2023 at 11:00 AM, Licensing Program Analysts (LPAs) L. Alexander and L. Hall arrived unannounced to conduct an continued 1-Year Annual Required inspection from previous visit on 07/26/2023. LPAs met with Caregiver, Marilin "Lin" Alegria and explained the purpose of the visit. LPA spoke with Administrator, Ogedi Okeigwe, via telephone. LPAs reviewed 4 resident files from previous visit on 07/26/23. LPAs reviewed 1 resident file on today's visit. LPAs reviewed 6 staff files and 5 of 6 staff had CPR/AED/First Aid training and associated to the facility. THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: LPAs observed during visit on 7/26/2023, that Licensee/Administrator was out of the country and had been for approximately a month and did not notified CCLD of their absence. There was no substitute Administrator notified. LPAs observed during record review that S4, S5 and S6 was missing health screening and TB tests. LPAs observed during record review and interview that R4 expired on 8/17/2023. Facility did not submit a death report to CCLD. LIC 809C Continued LIC 809 Continued... LPAs observed R1 was admitted into hospice services on 7/13/2023. Facility did not notify CCLD of hospice services. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 08/31/2023: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 24, 2023

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Annual/Random

On 07/26/2023 at 2:55 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Caregiver, Raynardo "Leon" Stewart and explained the purpose of the visit. The Acting Administrator, Winifred Wepee, was called and arrived shortly after. Hospice waiver for 2. The facility’s fire clearance was approved for 6 Non-Ambulatory of which 1 may be bedridden only in Bedroom #6. Hospice waiver for 2. LPA toured facility with Leon including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 8 total bedrooms which 6 bedrooms are occupied by the residents and 2 bedrooms is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 76 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 116.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 01/06/2023. First aid kit was observed to be complete. During visit LPA reviewed resident records but LPA will have to return at a later date to continue annual inspection. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 26, 2023

Allegation investigated: Resident (R1) developed pressure injury while in care. Facility failed to meet resident's (R1) care needs.

Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegations. LPA met with Winifred 'Willie' Wepee, facility manager. LPA called and spoke with Ogedi Okeigwe, administrator. LPA informed both the facility manager and administrator the reason for visit. It was alleged that R1 was admitted to the facility on 3/08/2021, but did not have hospital bed. R1 was left in the wheelchair overnight. It was further alleged that R1 was sent out to the hospital where he was found to have developed pressure injury and with dried feces on buttocks. ......continued on 9099C (page 2) Substantiated Page 2 During the course of investigation, the Department obtained copies of R1’s documents including but not limited to the following: medical records; LIC601 Identification and Emergency Information; Admission Agreement; LIC602A Physician's Report; Pre-placement Appraisal; hospital documents. Copies of LIC9020 Register of Facility Clients/Residents and LIC500 Personnel Report were obtained, and interviews conducted. Medical records showed R1 was admitted to the hospital on 3/09/2021 with generalized buttocks pain. R1 was observed with skin breakdown but no pressure injury, wounds or incision. Medical records also revealed R1 had large amount of soft stool that appears to have been on R1’s skin for some time as it was difficult to remove and dried in some areas. R1 indicated that he tell the facility staff that he had bowel movement but sometimes it takes a while for them to clean him up. Staff (S1) stated when R1 moved-in, R1’s hospital bed and lift was not delivered that night and R1 slept in a wheelchair all night, because the facility didn’t have a lift. R1 was discharged back to the facility on 3/10/2021 with after care instructions on how to care for non-specific dermatitis. On 03/30/2021, R1 was visited by Home Health at the facility and was observed with altered mental state. R1 was sent out and admitted to the hospital with final diagnosis of severe sepsis with acute organ dysfunction and unstageable pressure injury of sacrum/buttocks. Staff interviews were conducted, and staff (S1 & S2) had a hard time recalling if R1 had pressure injury. S1 indicated that on the day of admission to the facility, R1’s hospital bed was delivered but not accepted by the facility due to bed was not electric. .......continued on 9099C (page 3) Page 3 Director for Home Health and Hospice (HHD) stated R1 receives home health care for catheter care and seen by home health nurse twice a week. HHD stated that on 03/09/2021, home health called the facility to schedule a visit but was notified that R1 was at the hospital. Home Health nurse (HH) was interviewed who stated that R1 had stage 1 pressure injury and unstageable deep tissue pressure injury while at the facility’s care. HH indicated that R1 could have developed the first pressure injury for spending the night at R1’s wheelchair. HH went over the care of pressure wounds with the staff. Based on records review and interviews, allegations of “Resident (R1) developed pressure injury while in care”, and “Facility failed to meet resident's (R1) care needs.” are substantiated. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies are cited from Title 22 California Code of Regulations and listed on 9099D. A $500.00 civil penalty is assessed. Failure to submit proof of corrections by plan of correction due dates may result in additional civil penalties. Deficiencies, plan and proof of corrections and civil penalty were discussed with the administrator over the phone in the presence of the facility manager. Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Nov 16, 2022 · control 15-AS-20210629164337

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(6) · Plan of correction due date: Nov 17, 2022

§1569.269 Enumerated rights; severability: (a) Residents of residential care facilities for the elderly shall have all of the following rights:(6) To care, supervision, and services that meet their individual needs and are delivered -This requirement is not met as evidenced by: .. -Based on records review and interviews, the licensee did not comply with the section above for R1 who developed unstageable pressure injury. R1 also sustained severe sepsis and acure organ dysfunction while in care which posed immediate health risk to person in care. Civil penalty is assessed.the state’s words, verbatim · CDSS document, Nov 16, 2022

Plan of correction: R1 is no longer at the facility. Administratror to in-service the staff. Copy of in-service training with attendees signatures to be submiited by 11/17/2022. A$500.00 civil penalty is assessed on this day.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Nov 30, 2022

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). -This requirement is not met as evidenced by: .. --Based on records review and interviews, the licensee did not comply with the section above for not meeting R1's needs, R1 was found to have dried feces when sent out to the hospital.the state’s words, verbatim · CDSS document, Nov 16, 2022

Plan of correction: R1 is no longer at the facility. Administratror to in-service the staff and ensure residents' care needs are met. Copy of in-service training with attendees signatures to be submiited by 11/30/2022.

Type of visit: Case Management - Deficiencies

During investigation of complaint (Complaint Control # 15-AS-20210629164337) and upon review of documents, the Department learned that upon admission of resident (R1), the facility did not conduct an intake evaluation and document any pre-existing marks or injuries on resident. Staff (S1) stated R1 had a bandage on backside when R1 arrived to the facility from the Emergency Department on 3/10/2021, but it was not documented anywhere. The facility keeps limited records and did not document a change in condition or keep progress notes on R1’s condition. On this day, November 16, 2022, Licensing Program Analyst (LPA) Delmundo arrived to the facility unannounced and met with staff, Winifred 'Willie' Wepee, facility manager, and informed the reason for visit. LPA called and spoke with Ogedi Okeigwe, administrator, over the phone and informed of the above. Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of correction by plan of correction due date may result in civil penalty. Deficiency and plan and proof of correction were discussed with the administrator over the phone in the presence of the facility manager. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Nov 16, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Nov 30, 2022

87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning, and that appropriate assistance is provided when such observation reveals unmet needs. ..... the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. -This requirement is not met as evidenced by: Based on interview and records review, the licensee did not comply with the section above for not properly observing and documenting resident's changes in condition.the state’s words, verbatim · CDSS document, Nov 16, 2022

Plan of correction: R1 is no longer at the facility. Administrator will come up wth a plan on how to properly observe and document changes in residents and communicate the changes to all the parties involved in residents' care needs.

Allegation investigated: Facility does not have on call night staff.

On 8/13/2021 starting at 9:58am, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to deliver findings for the above allegation. Upon arrival, LPA met with back-up Administrator, Winifred Wepee. During the course of the investigation, LPA P. Singh conducted 10-day initial investigation on 12/19/2019. On 8/11/2021, LPA L. Francisco interviewed S1 over the phone and obtained a copy of facility's Personnel Report (LIC 500) via email for October 2019 to December 2019. Based on record review, a night shift staff is scheduled to work from 10pm-7am. No forthcoming information provided by reporting party. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 13, 2021 · control 15-AS-20191216122901

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Delmundo conducted a health and safety inspection as a result of the Department receiving a complaint (Control # 15-AS-20210629164337). LPA called and informed Ogedi Okeigwe, administrator, the purpose of visit and inspection. Ogedi authorized Winifred Wepee to be with LPA during inspection. Ogedi arrived after about 2 hours. LPA toured the facility inside out with Winifred Wepee LPA inspected the living room, kitchen, dining area, bedrooms, bathrooms, side and backyards. There were 3 staff on-duty and 2 residents present. Facility has 8 bedrooms, 6 designated for residents use and 2 for staff. Facility has sufficient lighting. Hallways and passageways were observed free of obstructions. Knives were observed in a locked cabinet in the kitchen. Exit interview conducted and copy of this report provided to Ogedi Okeigwe.the state’s words, verbatim · CDSS document, Jul 8, 2021