Emerald Oaks

Type of visit: Required - 1 Year

LPA Hiratsuka, conducted this unannounced annual visit. LPA wore a surgical mask and observed all staff wearing surgical masks. LPA was also screened by the front desk. The main entrance opens to the main hallway. The administration offices are to the right of the main entrance. This facility has a hallway on the left that leads to the kitchen, main dining room, and leads back to another hallway. There are two hallways on the right that are not connected to each other. The second hallway in the back that goes to the right leads to the activity area. There are three short hallways that lead off from the very back hallways with the ends leading to the outside. There are two outdoor areas and they are both enclosed. This facility has 59 resident rooms; three have full private bathrooms and the rest have half private bathrooms. There is a medication room to the right past the administration offices. Multiple topics discussed. Several resident records were reviewed Several staff files were reviewed. The following shall be updated and submitted to licensing within 30 days; LIC 500- facility personnel or staff schedule LIC 308- designation of administrative responsibility LIC 610- emergency disaster plan No deficiencies cited.the state’s words, verbatim · CDSS document, Oct 19, 2023

Allegation investigated: Facility not communicating with responsible party

LPA Hiratsuka, conducted the investigation into the allegation above. LPA interviewed staff and the complainant. Administrator Assistant Ivy Garner stated she did not notify the responsible party of the missing item because she thought it was communicated to the responsible party by another family member of the resident in question. Facility had already contacted the doctor to make adjustments to the resident's dietary needs. Based on the above, the allegation is substantiated.the state’s words, verbatim · CDSS document, Apr 24, 2023 · control 25-AS-20230103141558

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: May 24, 2023

Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: 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 is not met as evidenced by: Based on LPA's interviews the facility did not communicate the missing item to the responsible party. This does not pose an immediate risk to residents.the state’s words, verbatim · CDSS document, Apr 24, 2023

Plan of correction: By 05/24/2023, the licensee shall submit in writing a communication plan to ensure responsible parties are notified regarding resident personal belongings going missing.

Type of visit: Case Management - Deficiencies

LPA Hiratsuka, conducted this case management in response to a complaint investigation. While investigating complaint control number 25-AS-20230103141558, LPA learned a resident wore dentures. LPA reviewed the resident's written plan of care and annual assessments. Both did not mention the resident wore dentures. The resident's physician's report stated the resident wears dentures. The documentation also did not state the resident's physical and mental capabilities to wearing the dentures because the resident had dementia. The regulations requires that assessment are to be done annual and while they did the assessment annually, it did not address the dentures. The assessment and written plan of care just stated the resident required assistance eating. Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code. Failure to correct shall result in civil penalties. appeal rights left.the state’s words, verbatim · CDSS document, Apr 24, 2023

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

Care of Persons with Dementia. Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by:Based on LPAs interivews everyone knew resident required dentures but it was not written down. This does not pose an immediate risk to residents.the state’s words, verbatim · CDSS document, Apr 24, 2023

Plan of correction: By 05/24/2023, the facility shall ensure all written plans of care and assessments are complete. Licensee shall submit in writing how they shall ensure all are complete.

Type of visit: Required - 1 Year

LPA Hiratsuka, conducted this unannounced annual visit. LPA wore a surgical mask and observed all staff wearing surgical masks. LPA was also screened by the front desk. The main entrance opens to the main hallway. The administration offices are to the right of the main entrance. This facility has a hallway on the left that leads to the kitchen, main dining room, and leads back to another hallway. There are two hallways on the right that are not connected to each other. The second hallway in the back that goes to the right leads to the activity area. There are three short hallways that lead off from the very back hallways with the ends leading to the outside. There are two outdoor areas and they are both enclosed. This facility has 59 resident rooms; three have full private bathrooms and the rest have half private bathrooms. There is a medication room to the right past the administration offices. Multiple topics discussed. Several resident and staff files were reviewed. The following shall be updated and submitted to licensing within 30 days; LIC 500- facility personnel or staff schedule LIC 308- designation of administrative responsibility LIC 610- emergency disaster plan No deficiencies cited.the state’s words, verbatim · CDSS document, Dec 1, 2022

Type of visit: Case Management - Other

Donna Gurriere, Licensing Program Analyst was in contact and met with Ivy Garner, Assistant Administrator. LPA Gurriere completed the required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID 19 infection to affirm no COVID-19 related symptoms. The administrator/staff person was contacted to complete a facility risk assessment. LPA Gurriere ensured that hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. Additionally, LPA Gurriere was screened by a staff person upon entering the facility. The purpose of the case management visit is to advise Ms. Garner that It was reported that during a complaint visit on 04/12/22, the staff persons at the facility used a Hoyer Lift to transport a resident from her bed to the bathroom. Administrator and staff did not feel that there was an issue, as two staff persons assisted in making the transfer. Upon further investigation, it was determined that the Hoyer Lift is only to be used to transfer a resident from the bed to the wheelchair or to a bedside commode. A Hoyer Lift is not to be used as any type of “transfer” from one room to the next. Administrator agrees that she understands the purpose of a Hoyer Lift. No deficiencies cited.the state’s words, verbatim · CDSS document, Jun 21, 2022

Type of visit: Case Management - Incident

Licensing Program Analysts (LPA) Mai Thao and IB Investigator Melissa Bennett arrived at the facility to conduct an unannounced case management visit. LPA met with Sarah Thomas, Residential Service Director and Ivy Garner, ED in Training. LPA explained the purpose of the visit. Prior to initiating the case management visit, LPA and IB Investigator 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 and IB Investigator ensured they wash their hands before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 and surgical mask. In addition, Staff screened LPA and IB Investigator prior to entering the facility. It was reported to Licensing on January 6, 2022 that on 12/25/2022, Resident 1 (R!) had an unwitnessed fall, was sent out to the Emergency Room (ER), and sustained a fracture. During today's visit, LPA, IB investigator, RSD and ED in Training discussed the incident. Through record review, it was observed that R1 was under the care of Hospice. RSD and ED in Training stated that resident was on a precaution 2 hour checks that were documented on logs. RSD and ED stated that R1 is able to use the bathroom independently and may require stand-by assist if needed. LPA and IB investigator reviewed R1 LIC 602 Physician's Report and Care Plan. LPA did not observe R1 activities of daily living (ADLs) being address. LPA advised facility on updating care plans to meet changes in condition. LPA observed that R1 had a Hospice Care Plan on file. LPA observed on facility documentation that staff last checked on resident at 6:55pm and at 7pm staff heard resident calling for help. The facility immediately went to the resident, assess the incident, and contacted 911. No citations were observed during this visit. An exit interview was conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, May 18, 2022

Allegation investigated: A resident was left in a soiled diaper for 2.5 days. Staff are not giving a resident prescribed medication for a rash.

Donna Gurriere, Licensing Program Analyst was in contact and met with Ivy Garner, Assistant Administrator. It was alleged that A resident was left in a soiled diaper for 2.5 days and that Staff are not giving a resident prescribed medication for a rash. LPA Gurriere completed the required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID 19 infection to affirm no COVID-19 related symptoms. The administrator/staff person was contacted to complete a facility risk assessment. LPA Gurriere ensured that hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. Additionally, LPA Gurriere was screened by a staff person upon entering the facility. continued Unsubstantiated A resident was left in a soiled diaper for 2.5 days. During the investigation process the assistant administrator and seven staff persons were interviewed. In addition, an attempted interview was conducted with the resident (Resident 1); however, he was not able to respond to the asked questions due to his diagnosis. Documentation was received and reviewed to include the Physician’s Report, Admission Agreement, Appraisal and Needs Plan, Medication Administrative Record (MARs) and a doctor’s order from the Veteran’s Affairs (VA). In addition, three residents’ medications were reviewed. It was reported by all staff persons interviewed that they were not aware that the resident was left in a soiled diaper for 2.5 days. It was reported that the resident was difficult in that he was aggressive and combative, and at times would refuse to be changed by the staff persons. A doctor’s order was obtained from the Veteran’s Affairs (VA) Nurse Practitioner which stated, “The public guardian should be notified, and the patient should be sent to local emergency room for evaluation if he refuses perineal or incontinence care for any period of time exceeding 8 hours.” Staff reported that the resident had his medications changed and that he is now more amenable to having his briefs changed. It could not be proven that A resident was left in a soiled diaper for 2.5 days. Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated. continued During the investigation process the assistant administrator and seven staff persons were interviewed. In addition, an attempted interview was conducted with the resident (Resident 1); however, he was not able to respond to the asked questions due to his diagnosis. Documentation was received and reviewed to include the Physician’s Report, Admission Agreement, Appraisal and Needs Plan, Medication Administrative Record (MARs) and a doctor’s order were reviewed. In addition, three residents’ medications were reviewed. It was reported by all staff persons that they were giving the resident his prescribed medication (Zinc Oxide) for a rash. It was reported that when the resident would refuse to be changed, the staff persons could not apply the cream. A review of cream medications for three of the residents were observed and their medications were in compliance. It could not be proven that Staff are not giving a resident prescribed medication for a rash. Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated.the state’s words, verbatim · CDSS document, May 3, 2022 · control 25-AS-20211027151708

Allegation investigated: Staff not providing accurate dosage of medication to a resident. Unqualified staff are administering medication to residents. Residents diapers are not changed in a timely manner resulting in a rash. Staff are not responding to residents call button in a timely manner. Resident's belongings were stolen. Staff are not providing food to a residenet in a timely manner. Staff are not providing adequate food service for a resident. Staff are not providing residents with food of good quality.

Donna Gurriere, Licensing Program Analyst was in contact and met with Ivy Garner, Assistant Administrator, in regards to the above mentioned allegations. LPA Gurriere completed the required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID 19 infection to affirm no COVID-19 related symptoms. The administrator/staff person was contacted to complete a facility risk assessment. LPA Gurriere ensured that hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. Additionally, LPA Gurriere was screened by a staff person upon entering the facility. continued Unsubstantiated Staff are not providing an accurate dosage of medication to a resident. During the interview process, the assistant administrator and four staff persons were interviewed. The resident (Resident 1) was not interviewed, as she is no longer residing at the facility. Documents were collected which included Hospice Records, Physician’s Report, Admission Agreement and Pre-Placement Appraisal. Staff persons stated that they were not aware of an inaccurate dosage of medication that was given to a resident (Resident 1). It was reported that the resident was on hospice and not only were the med technicians ensuring that the medication was given correctly, it was reviewed by the hospice nurse also. The resident has since moved, and her medications could not be reviewed; however, during the process of this investigation, a site visit was conducted, and three residents were randomly selected for medication review. Medications were present and were in order, as required. It could not be proven that Staff are not providing an accurate dosage of medication to a resident. Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated. No deficiencies cited. Unqualified staff are administering medication to residents. During the interview process, the assistant administrator and four staff persons were interviewed. In addition, documents were collected which included Hospice Records, Physician’s Report, Admission Agreement, Pre-Placement Appraisal and Relias Computer Training Records. continued Required Training for staff hired after 01/01/16 includes: Cultural Competency, Personal Care Services; Physical Limitations and Needs of the Elderly; Residents’ Rights; Dementia Care; Building and Fire Safety and Appropriate Response to Emergencies; Antipsychotic and Psychotropic Medications; Policies and Procedures Regarding Medications; and Postural Supports, Restricted Health Conditions and Hospice Care. It was reported and verified that staff persons are trained through Relias Online Training and then provided training by shadowing a more experienced staff person for the required 16-hour initial training. In addition, transcripts for three employees were reviewed to indicate that they had the appropriate training, in administering medications to residents. It could not be proven that the Unqualified staff are administering medication to residents. Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated. No deficiencies cited. A resident’s diapers were not changed in a timely manner which resulted in a rash. During the interview process, the assistant administrator and four staff persons were interviewed. The resident (Resident 1) has moved and was not interviewed. In addition, documents were collected which included Hospice Records, Physician’s Report, Admission Agreement and Pre-Placement Appraisal. Hospice notes indicated that Resident 1 was able to make her basic needs known to the staff persons, which was supported by staff statements during the interview process. Peri care was recommended by the hospice nurse to include changing incontinent care products and to ensure that the resident did not suffer from a skin breakdown. A review of the hospice notes indicated that the resident did not have a rash, wound, or ulcer/bed sores. In addition, staff persons follow a “Tier Level System” with resident names that indicate which residents are incontinent and need assistance with being clean and dry with their incontinent products. continued It could not be proven that A resident’s diapers were not changed in a timely manner, which resulted in a rash. Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated. No deficiencies cited. Staff are not responding to residents’ call buttons in a timely manner. During the interview process, the assistant administrator and four staff persons were interviewed. The resident (Resident 1) has moved and was not interviewed. In addition, documents were collected which included Hospice Records, Physician’s Report, Admission Agreement, Pre-Placement Appraisal and Inservice Training on Call Bell Policy and Procedures. Staff persons signed off that they were present for the training. Staff persons were interviewed, and they reported that they try to respond to the call buttons within a five-minute period. The training that was provided to the staff stated that if the staff person on call for the resident could not attend the resident within the five-minutes, then it is their responsibility to radio another staff person to assist. Overall, it was reported that staff respond to the residents in a timely manner. It could not be proven that Staff are not responding to residents’ call buttons in a timely manner. Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated. No deficiencies cited. continued A resident’s belongings were stolen. During the interview process, the assistant administrator, and four staff persons were interviewed. In addition, the Ombudsman advised that she met with the resident to discuss the resident’s Property and Valuables List. The resident (Resident 1) has moved and was not interviewed. In addition, documents were collected which included Hospice Records, Physician’s Report, Admission Agreement, Pre-Placement Appraisal and Personal Property and Valuables List for the resident. It was reported and documents reviewed, that the assistant administrator along with the Ombudsman reviewed the resident’s Personal Property and Valuables List (two lists) with the resident. The assistant administrator and the Ombudsman could not determine or substantiate any of the resident’s items missing. It could not be proven that A resident’s belongings were stolen. Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated. No deficiencies cited. continued Staff not providing food to a resident in a timely manner. Staff are not providing adequate food service to a resident. Staff are not providing residents with food of good quality. During the interview process, the assistant administrator, four staff persons, two cooks and three residents were interviewed. The resident (Resident 1) has moved and was not interviewed. The facility’s food service policy and menu were reviewed. It was reported that meals are served at 8:00 a.m., 12:00 p.m., and 5:00 p.m. and that snacks are provided twice a day. It was stated that residents either eat in the dining room or in their rooms. An unannounced walk through of the kitchen was conducted and the lunch menu consisted of Salisbury steak, green beans, potatoes with gravy, rice crispy treats and/or sugar free Jell-O. The cook advised that she serves 50 residents in the dining area and 11-15 residents are given tray service in their rooms. The cook stated that the care providers and the med technicians assist when serving the residents, as needed. Dinner was also in preparation and was observed to be lemon chicken, vegetables and rolls. The food being served appeared to be of good nutrition and was being served hot. A menu was observed in the kitchen and the cook was following the daily menu. During the interview process, overall, it was reported that the residents do receive their food in a timely manner, that there was adequate food and that the food was of good quality. It could not be proven that Staff are not providing food to a resident in a timely manner, Staff are not providing adequate food service to a resident and Staff are not providing residents with food of good quality. Although the allegations may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are Unsubstantiated. During the investigation of this Complaint #25-AS-20211011102847, a deficiency was noted and shall be cited on a separate Facility Evaluation Report (LIC 809).the state’s words, verbatim · CDSS document, Apr 26, 2022 · control 25-AS-20211011102847

Type of visit: Case Management - Deficiencies

During the investigation of Complaint #25-AS-20211011102847, a deficiency was noted and shall be cited on this LIC 809 document. Donna Gurriere, Licensing Program Analyst was in contact and met with Ivy Garner, Assistant Administrator. LPA Gurriere completed the required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID 19 infection to affirm no COVID-19 related symptoms. The administrator/staff person was contacted to complete a facility risk assessment. LPA Gurriere ensured that hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. Additionally, LPA Gurriere was screened by a staff person upon entering the facility. continued During the visit to investigate residents that were incontinent with bladder issues, it was noted that there was an odor of urine in the hallway. The assistant administrator reported that they had a resident (Resident 1) residing in the facility that had incontinent issues and that when she stood up, she would not have control over her bladder, and she would wet on the carpet. The assistant administrator reported that the facility was in the process of changing out the carpet in the resident’s room. Based on the evidence obtained, the preponderance of evidence standard has been met; therefore, the deficiency is found to be Substantiated. California Code of Regulations (Title 22) is being cited on the attached LIC 809D. Appeal rights were provided, and the exit interview conducted. continuedthe state’s words, verbatim · CDSS document, Apr 26, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: May 17, 2022

Managed Incontinence - In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. LPA witnessed the facility smelling of urine. The licensee did not ensure that the facility remains free of odors from incontinent residents. This poses a potential safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 26, 2022

Plan of correction: The Assistant Administrator agrees to develop a plan for the incontinent resident to ensure that she is clean and dry. In addition, the Assistant Administrator agrees to have the carpets cleaned, removed and replaced.

Allegation investigated: Residents do not receive food in a timely manner Staff serve residents cold food. Staff do not follow protocol to prevent the spread of illness. Facility has bed bugs.

Donna Gurriere, Licensing Program Analyst was in contact and met with Ivy Garner, Assistant Administrator. It was alleged that Residents do not receive food in a timely manner, Staff serve residents cold food, Staff do not follow protocol to prevent the spread of illness and Facility has bed bugs. LPA Gurriere completed the required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID 19 infection to affirm no COVID-19 related symptoms. The administrator/staff person was contacted to complete a facility risk assessment. LPA Gurriere ensured that hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. Additionally, LPA Gurriere was screened by a staff person upon entering the facility. Unsubstantiated Residents do not receive food in a timely manner and Staff serve residents cold food. During the investigation process, the administrative assistant, five staff persons and five residents were interviewed. In addition, the facility’s food service policy and menu were reviewed. It was reported that meals are served at 8:00 a.m., 12:00 p.m., and 5:00 p.m. and that snacks are provided twice a day. It was stated that residents either eat in the dining room or in their rooms. A walk through of the kitchen was conducted and the lunch menu consisted of Salisbury steak, green beans, potatoes with gravy, rice crispy treats and/or sugar free Jell-O. The cook advised that she serves 50 residents in the dining area and 11-15 residents are given tray service in their rooms. The cook stated that the care providers and the med technicians assist when serving the residents, as needed. Dinner was also in preparation and was observed to be lemon chicken, vegetables and rolls. The food being served appeared to be of good nutrition and was being served hot. A menu was observed in the kitchen and the cook was following the daily menu. During the interview process, overall, it was reported that the residents do receive their food in a timely manner and that residents are not served cold food. It could not be proven that Residents do not receive food in a timely manner and that Staff serve residents cold food. Although the allegations may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are Unsubstantiated. continued Staff do not follow protocol to prevent the spread of illness. During the investigation process, the administrative assistant, four staff persons and two residents were interviewed. In addition, supportive documents that were provided included a Physician Reports, Admission Agreements, Resident Appraisal and laboratory results. It was reported that two residents (Resident 1 and Resident 2) may have had Clostridium Difficile (C-Diff). During the interview process, it was stated that during the month of January 2021 it was suspected that the residents had C-Diff; therefore, the staff set up a Personal Protective Equipment (PPE) station near the residents’ rooms for precautions. The facility provided copies of the C-Diff results which indicated that the residents were negative. It could not be proven that Staff do not follow protocol to prevent the spread of illness. Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated. Facility has bed bugs. During the investigation process, the administrative assistant, four staff persons and two residents were interviewed. In addition, invoices were received and reviewed from the pest control company. continued Prior to the complaint and during the month of June 2021, a pest control company was treating the facility for bed bugs. In addition, when the facility noticed that they had bed bugs, they notified the licensing agency via incident report. The administrator assistant reported that the pest control company continues to come to the facility on a monthly basis and also checks specifically for bed bugs. Copies of invoices from the pest control company were provided and verified for the months of January through June 2021. Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated.the state’s words, verbatim · CDSS document, Apr 12, 2022 · control 25-AS-20210621084647

Allegation investigated: A resident is being transferred from bed to toilet in an unsafe manner. Resident was left in bed in her own urine.

Donna Gurriere, Licensing Program Analyst was in contact and met with Ivy Garner, Assistant Administrator. It was alleged that A resident is being transferred from bed to toilet in an unsafe manner and Resident is being left in her bed in her own urine. LPA Gurriere completed the required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID 19 infection to affirm no COVID-19 related symptoms. The administrator/staff person was contacted to complete a facility risk assessment. LPA Gurriere ensured that hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. Additionally, LPA Gurriere was screened by a staff person upon entering the facility. Unsubstantiated A resident is being transferred from bed to toilet in an unsafe manner. During the investigation process the assistant administrator and five staff persons were interviewed. In addition, the resident (Resident 1) was interviewed. Documentation was received and reviewed to include the Physician’s Report, Admission Agreement, How to use a Hoyer Lift requirement and a Hoyer Lift Inservice Signoff document. During the initial visit at the facility, Misty Valencia and Dawn Keene, two Licensing Program Analysts (LPAs) went to the resident’s room to view the concern of the Hoyer Lift being moved from the resident’s bed to the bathroom. It was reported and observed by the LPAs that the threshold was at a “normal height.” All staff persons reported that there was not a problem with using the Hoyer Lift with the resident and that the Hoyer Lift was always used with two staff persons assisting. The resident was interviewed, and she reported that she felt “safe” when the staff persons were using the Hoyer Lift. There was no report that an incident occurred with a transfer in an unsafe manner. Records were received and reviewed indicating that staff have been trained in using a Hoyer Lift. It could not be proven that A resident is being transferred from bed to toilet in an unsafe manner. Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated. continued Resident left in bed in her own urine. During the investigation process the assistant administrator and five staff persons were interviewed. The resident (Resident 1) was not interviewed, as she is no longer residing at the facility. Documentation was received and reviewed to include the Physician’s Report and Admission Agreement. It was reported that the resident needed assistance in incontinence issues. All staff persons advised that they were not aware that the resident was left in bed in her own urine, as the resident was on an incontinence schedule that they followed. It could not be proven that A resident was left in her bed in her own urine. Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated. Although it was not indicated that the resident was left in bed in her own urine, the staff are required to follow a bowel and bladder program developed by a skilled professional. The staff have indicated that they followed a schedule; however, the staff have not been trained by a skilled professional, as required. Based on this information, the facility shall be cited on a separate report, LIC 809, on this date. (See LIC 809).the state’s words, verbatim · CDSS document, Apr 12, 2022 · control 25-AS-20210722143123

Type of visit: Case Management - Deficiencies

During the investigation of Complaint #25-AS-20210722143123, dated 07/22/21 a deficiency was noted and shall be cited on this LIC 809 document. The initial allegation was that a Resident was left in bed in her own urine. Donna Gurriere, Licensing Program Analyst was in contact and met with Ivy Garner, Assistant Administrator. It was alleged that a resident (Resident 1) is being left in her bed in her own urine. LPA Gurriere completed the required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID 19 infection to affirm no COVID-19 related symptoms. The administrator/staff person was contacted to complete a facility risk assessment. LPA Gurriere ensured that hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. Additionally, LPA Gurriere was screened by a staff person upon entering the facility. Although it was not indicated that the resident was left in bed in her own urine, the staff are required to follow a bowel and bladder program developed by a skilled professional. The staff have indicated that they followed a schedule; however, the staff have not been trained by a skilled professional, as required. Based on the evidence obtained, the preponderance of evidence standard has been met; therefore, the deficiency is found to be Substantiated. California Code of Regulations (Title 22) is being cited on the attached LIC 809D. Appeal rights were provided and the exit interview conducted.the state’s words, verbatim · CDSS document, Apr 12, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87625(b)(5) · Plan of correction due date: Apr 13, 2022

87625 (b)(5) Managed Incontinence - In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: Ensuring that the appropriately skilled professional developing the bowel and/or bladder program provide training to facility staff responsible for implementation of the program. The licensee did not ensure that training was provided by a skilled professional for staff that are providing incontinence care to residents. This poses an immediate safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 12, 2022

Plan of correction: The Assistant Administrator agrees to enroll staff persons in training with a skilled professional in regard to Managed Incontinence. Assistant Administrator shall have staff enrolled by 04/13/22 and shall submit a list of staff persons names that are being trained. Assistant Administrator agrees to submit the date of training.

Type of visit: Required - 1 Year

12/08/2021 12:02 PM Licensing Program Analyst (LPA) Dawn Keane arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Ivy Garner Assistant Executive Director (ED) 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 ED 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: N95. Additionally, LPA Keane was screened by ED/staff person. LPA Keane and ED toured facility to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, two (2) bathrooms, four (4) bedrooms, kitchen, storage areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA Keane and the ED 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 ED.the state’s words, verbatim · CDSS document, Dec 8, 2021

Type of visit: Case Management - Incident

Donna Gurriere, Licensing Program Analyst (LPA) arrived at the facility unannounced to conduct a case management visit regarding an incident. LPA Gurriere completed the required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID 19 infection to affirm no COVID-19 related symptoms. The administrator/staff person was contacted to complete a facility risk assessment. LPA Gurriere ensured that hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical mask. Additionally, LPA Gurriere was screened by administrator/staff person upon entering the facility. On 05/04/21 it was reported that a resident (Resident 1) had an unwitnessed fall and was found laying on the ground in his room. The resident suffered a head injury and a humeral fracture. The resident was transported to the hospital. Later that day, the resident was returned to the facility. The resident was advised to not use the restroom unless he had supervision. Resident was placed on hospice and then passed away approximately one month later. On 05/16/21 it was reported that a resident (Resident 2) had an unwitnessed fall and was found on the floor in his room. The resident had a laceration on the back of his head. The resident was sent to the hospital and returned later on the same day. The resident did not need sutures and is doing well. The resident is currently on 15 minute checks. An exit interview was conducted, and a copy of the report was given to the administrator. No deficiencies cited.the state’s words, verbatim · CDSS document, Aug 31, 2021