Bluemeadow Care

Allegation investigated: Facility not properly storing medications.

On 4/04/2023 at 9:45AM, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct complaint investigation for the above allegation. LPA met with Administrator Yanlin "Cynthia" Huang and explained the purpose of the visit. During the complaint investigation, LPA conducted a tour of the medication closet and interview with S1. LPA observed 3 to 5 days of pre-poured medication transferred into a weekly pill organizer for all 5 residents. S1 stated that S1 pre-poured /transfered the medication in the weekly pill organizer for all 5 residents. Based on LPAs observations and interview, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted. Appeal Rights and a copy of this report provided. Substantiatedthe state’s words, verbatim · CDSS document, Apr 4, 2023 · control 15-AS-20230328172856

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(5) · Plan of correction due date: Apr 11, 2023

(h) The following requirements shall apply to medications which are centrally stored: (5) 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 evidence by: Based on LPA's observation licensee did not coply with the section cited above by having medication transferred into a weekly pill organizer which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 4, 2023

Plan of correction: Licensee/Administrator will submit a written statement of having read and understood the regulation and conducted in-service training with all staff, providing CCLD with a copy of all signatures of staff attended no later than the POC date.

Type of visit: Required - 1 Year

On 3/23/2023 starting 10:10 AM, Licensing Program Analysts (LPAs) L. Francisco and L. Fici arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Administrator, Yanlin "Cynthia" Huang and explained the purpose of the visit. The facility’s fire clearance was approved for all six (6) non-ambulatory residents of which 1 may be bedridden. There were 2 staff and 5 residents present during inspection. Starting at 10:25 AM, LPAs toured facility with Administrator including but not limited to bedrooms, 2 bathrooms, kitchen, common area and backyard. The facility consists of 7 total bedrooms which 6 bedrooms are for residents and 1 bedroom is for staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 68 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in residents’ shared bathroom was measured at 141 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. Sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was observed fully charged. First aid kit was observed to be complete. Starting at 11:30 AM, LPAs reviewed 4 of 5 residents records. At 12:30 PM, LPAs reviewed 1 of 3 staff records. At 4:00 PM, LPAs reviewed a sample of resident’s medications. REPORT CONTINUES ON 809C THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: -At 10:40 AM, LPA observed hot water temperature is maintained at 141 degrees F -At 10:45 AM, LPA observed a bed in garage and being used as a sleeping area. -Starting at 11:38 AM during record review, LPAs observed no files are being maintained for S1 and S2. Required training were missing. Records for R5 was not maintained at facility. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 3/31/2023: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance Current Administrator’s Certificate 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. An immediate $500 Civil Penalty is being assessed. Exit interview conducted with Administrator. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 24, 2023

The state marks this report as 16 pages; the online copy we transcribed has 14. You can request the full file from the county licensing office.

Allegation investigated: Resident developed a pressure injury requiring hospitalization Resident had an unexplained injury

On 1/12/2023 starting at 9:30 AM, Licensing Program Analysts (LPAs) L. Francisco and C. Lin arrived unannounced to deliver findings for the above allegations. LPAs met with Administrator, Yanlin “Cynthia” Huang and explained the purpose of the visit. During the course of investigation, the Department conducted interviews with facility staff, witnesses and complainant and reviewed records. Documents including but not limited to: Resident 1 (R1) needs and services plan, physician’s report, care plan, incident reports, photos of resident, discharge notes, and home health notes were obtained. REPORT CONTINUED ON 9099C Substantiated The Department investigated resident developed a pressure injury requiring hospitalization. Based on record review, R1 was admitted to the facility on June of 2015 under the prior License. Sometime in April 2020, R1’s right heel bumped on the wheelchair. On 4/8/2020, R1’s wound was diagnosed unstageable by attending physician at John Muir Hospital and wound care was initiated. The same day, home health nurse instructed facility staff to supervise R1 at all times, to off-load pressure to right heel at all times, feed R1 with high protein diet and to reposition every two hours. On 5/18/2020 and 6/5/2020, Home Health Nurse observed R1’s wound pressed against the bed despite instructions to off-load and elevate the heel with pillows. On 6/9/2020, R1 was admitted to Emergency Department and the pressure injury was diagnosed at Stage 4. Bone was exposed and 60% of the heel was necrotic tissue. Test results revealed R1 had Osteomyelitis due to bacterial infection which infected R1’s bloodstream. The Department investigated resident had an unexplained injury. On 5/28/2020, facility staff informed home health nurse that R1 had fallen from the wheelchair earlier in the day and sustained a skin tear to the chin when R1 leaned over in the wheelchair to pick up something. On 6/9/2020, caregiver advised R1’s left eye had been bleeding for the past two days but could not explain why or how R1 sustained the injury. Upon R1’s admission to the Emergency Department on 6/9/2020, R1 was diagnosed with bilateral conjunctivitis. Based on the Department’s observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) and Health and Safety Code are being cited on the attached LIC 9099D. A $500 Civil Penalty is being assessed. Civil penalty determination related to serious bodily injury is pending. Exit interview conducted. Appeal rights and a copy of this report was provided to Administrator. The Department investigated residents needs are not being met due to insufficient staffing. Based on interview with 3 staff and 3 residents, 3 of 3 staff and 3 of 3 residents stated that there are no issues with staffing. The Department investigated resident not afforded dignity while in care. Based on interview with 3 residents, 2 of 3 residents stated they are provided with privacy. During an interview with 3 staff, 3 of 3 staff stated they close the door when they are changing the residents and assisting residents in the bathroom. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation are UNSUBSTANTIATED. Exit interview conducted with Administrator and a copy of this report provided. Based on documents reviewed, facility contacted home health nurses regarding R1’s health status. This agency has investigated the complaint alleging staff did not notify resident’s authorized representative of resident’s change in condition. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint. There is no deficiency noted. Exit interview was conducted with Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 12, 2023 · control 15-AS-20210119151543

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(10) · Plan of correction due date: Jan 13, 2023

1569.269(a)(10) ENUMERATED RIGHTS; SEVERABILITY (a) Residents of residential care facilities for the elderly shall have all of the following rights: (10)To be free from neglect... This requirement is not met as evidenced by: Based on the Department’s interviews and record review, Licensee did not comply with the regulation cited above. In April 2020, Home Health nurse instructed staff to off-load pressure to R1’s right heel at all times and to reposition every 2 hours. Nurse observed R1’s wound pressed against the bed twice. On 6/9/2020, R1 was admitted to hospital and pressure injury was diagnosed at Stage 4. Bone was exposed and test results revealed R1 had Osteomyelitis due to bacterial infection which infected R1’s bloodstream.the state’s words, verbatim · CDSS document, Jan 12, 2023

Plan of correction: By POC date, Administrator will conduct training with staff on the Health and Safety Code 1569.269 Enumerated Rights; severability and submit proof of training with staff signatures to CCL by 1/13/2023 A Non-Compliance Conference (NCC) will be scheduled. A $500 Civil Penalty is being assessed. Civil penalty determination related to serious bodily injury is pending.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Jan 13, 2023

87466 OBSERVATION OF THE RESIDENT The licensee shall ensure that residents are regularly observed for changes in physical......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 the Department’s interviews and record review, Licensee did not comply with the regulation cited above. Facility staff were instructed by Home Health nurse to supervise R1 at all times. On 5/28/2020, R1 fell off the wheelchair which resulted to R1 sustaining a cut on the chin. On 6/9/2020, staff informed Home Health nurse that R1’s eyes have been bleeding for two days. R1’s primary doctor was not notified.the state’s words, verbatim · CDSS document, Jan 12, 2023

Plan of correction: By POC date, Administrator and staff will review Sec 87466 Observation of Resident and submit proof to CCL by 1/13/2023

Type of visit: Case Management - Deficiencies

On 1/12/2023 at 11:40 AM, Licensing Program Analysts (LPAs) L. Francisco and C. Lin conducted a Case Management (CM) and met with Administrator, Yanlin "Cynthia" Huang . LPAs explained to Administrator that this CM is being conducted in connection with a complaint investigated by the Department. During the course of investigation, the Department observed R1 fell off the wheelchair and sustained a cut on the chin in April 2020. On May 28, 2020, R1 was observed with bleeding eyes. The facility failed to send incident reports to CCL. While at the facility on 1/12/2023, LPAs observed the following deficiencies: -At 9:58 AM, LPAs observed R4 does not have an updated appraisal plan on file. -At 10:35 AM, LPAs observed laundry detergent on top of the dryer inside the unlocked laundry room. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided to Administrator.the state’s words, verbatim · CDSS document, Jan 12, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(2) · Plan of correction due date: Jan 19, 2023

87705(f)(2) CARE OF PERSONS WITH DEMENTIA (f)The following shall be stored inaccessible to residents with dementia:(2)...and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Based on observation, Licensee did not comply with regulation cited above. LPAs observed unlocked cleaning supplies in unlocked laundry room which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 12, 2023

Plan of correction: By POC date, Licensee will review regulation and conduct in-service training with all staff and submit a copy of training with staff signatures to CCL.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(a)(1)(D) · Plan of correction due date: Jan 19, 2023

87411(a)(1)(D) REPORT REQUIREMENTS (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the…(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any residents. This requirement is not met as evidenced by: Based on record review, Licensee did not comply with the regulation cited above. Facility did not submit incident reports for when R1 fell off the wheelchair and sustained a cut on the chin in April 2020. In addition on May 28, 2020 where R1 was observed with bleeding eyes which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 12, 2023

Plan of correction: By POC date, Administrator will review Sec 87211 Reporting Requirements and submit self-certification of understanding to CCL

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(5) · Plan of correction due date: Jan 24, 2023

87705(c)(5) CARE OF PERSONS WITH DEMENTIA (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(5) Each resident with dementia shall have an .... and a reappraisal done at least annually... This requirement is not met as evidenced by: Based on record review, Licensee did not comply with the regulation cited above. LPAs observed R4 does not have an updated appraisal on file which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 12, 2023

Plan of correction: By POC date, Administrator agrees to update R4's appraisal and submit a copy to CCL.

Allegation investigated: Facility has inappropriate locking device on facility doors.

On 2/25/2022 at 12:05 PM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to conduct complaint investigation for the above allegation. LPA met with Administrator Yanlin "Cynthia" Huang and explained the purpose of the visit. During the complaint investigation, LPA conducted a tour of the facility. Based on information obtained, facility has inappropriate locking device on facility doors. LPA observed a latch above the front main entrance and R1's exit door. Based on LPAs observationss, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted. Appeal Rights and a copy of this report provided. Substantiatedthe state’s words, verbatim · CDSS document, Feb 25, 2022 · control 15-AS-20220217133453

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(6) · Plan of correction due date: Feb 26, 2022

87568.1 Personal Rights of Residents in All Facilities (a) Residents...shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. Thiis requirment was not met as evidence by: Based on observation, Licensee did not comply with the regulation cited above. LPA observed a latch installed in the front main entrance door and R1's exit door which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 25, 2022

Plan of correction: Administrator agrees to review the regulation and remove the lock. Administrator is to submit a self-certification and photos to CCL by POC date.

Type of visit: Required - 1 Year

On 10/12/2021 starting at 11:40am, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to conduct Infection Control Inspection. LPA met with Administrator, Yanlin Huang and explained the purpose of the visit. During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. There is one central entry point for universal screening. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan on file. The following deficiency was observed: -At 12:35pm during record review, LPA observed no Emergency Disaster Plan (LIC 610E) maintained at the facility. The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 12, 2021

The state marks this report as 12 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.