Grace Living 2

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Teresa Camara arrived at the facility unannounced to conduct a required annual visit at 1:20 PM. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Ivy Sudjati and discussed the reason for the visit. The LPA, along with Administrator, toured the physical plant areas inside and outside to ensure there are no health and safety hazards. BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 5 total bedrooms – two (2) bedrooms are shared rooms, two (2) bedrooms are private rooms and one (1) room is for staff. RESTROOMS: Three (3) restrooms for resident use were observed to be clean and sanitary and in operating condition. The bathrooms and showers were also observed to have grab bars and non-skid mats. The LPA observed sufficient amounts of soap and paper products in each restroom. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, common seating area and dining room furniture was observed to be in good condition. The LPA observed the required postings. Fire extinguishers was last serviced 4/6/22. The smoke detectors and carbon monoxide were tested and functioned properly during the visit. The backyard had furniture appropriate for residents' use. Laundry room had locked storage area for supplies. KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Medication, knives and cleaning supplies were in locked cabinets. INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. The facility has a central point for symptom screening. LPA noted that the facility is allowing visitors for both indoor and outdoor visitation. The LPA observed an adequate supply of Personal Protective Equipment (PPE) and they are able to obtain more if needed The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate. No citations were issued during today's visit. Exit interview conducted. Copy of the report provided to administrator via email.the state’s words, verbatim · CDSS document, Feb 22, 2023

Allegation investigated: Staff neglect led to Resident #1 (R1) sustaining pressure injuries Staff neglected to seek timely medical attention for Resident #1 (R1)

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint visit to deliver final findings for the above allegations. The initial visit was conducted on 08/06/2020 by LPA Kristin Heffernan and a subsequent visit was conducted on 03/18/2022 by LPA Camara. During today’s visit, LPA Camara met with House Manager Allan Santos and explained the reason for the visit. On 08/05/2020, the Department received a complaint regarding allegations staff neglect led to Resident #1 (R1) sustaining pressure injuries while in care and facility staff did not seek timely medical attention for R1. (continued on 9099-C) Substantiated On 08/06/2020, between 3:44 p.m. and 4:50 p.m., LPA Heffernan conducted the initial complaint visit. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint investigation was conducted telephonically with the Administrator Ivy Sudjati and House Manager Allan Santos. The LPA conducted an interview with the administrator at 3:44 p.m. and physical plant tour via FaceTime at 4:10 p.m. The LPA requested copies of pertinent documents relevant to the investigation and noted further investigation would be required. On 09/18/2020, LPA Lyndia Sager was reassigned to this complaint investigation. On 12/04/2020 at 3:07 p.m. and on 12/08/2020 at 4:44 p.m. LPA Sager received pertinent records from the administrator. On 12/04/2020 at approximately 5:00 p.m., LPA Sager conducted a telephonic interview with a witness. On 03/18/2022, LPA Camara conducted an unannounced subsequent complaint visit. LPA met with House Manager Allan Santos and spoke with Administrator Ivy Sudjati over the phone. During the visit, LPA conducted a brief physical plant tour at 3:49 p.m., interviewed the house manager at 3:52 p.m. and interviewed the administrator at 3:57 p.m. over the phone. The administrator was unable to meet LPA at the facility and R1’s records were located offsite. LPA requested the administrator provide any logs they may have kept regarding R1’s incontinence care and repositioning schedule. The administrator notified LPA she did not think they had such logs, but she would check. LPA noted further investigation was required. On 03/21/2022, LPA Camara received an email from the administrator which stated they do not have any logs for the times staff repositioned R1 nor do they have logs regarding R1’s incontinence care. The administrator provided LPA Camara with documents she previously provided to LPA Sager. (continued on 9099-C) Information gathered throughout the investigation, reflects R1 was admitted to the facility, Grace Living 2, on 05/10/2020. Based on the Skilled Nursing Discharge Summary dated 05/09/2020, R1 was recovering from a hip fracture for which R1 received physical and occupational therapy. R1 continued receiving physical therapy at the facility from a home health agency. R1 was discharged from physical therapy on 07/14/2020. While at the facility, R1 developed pressure injuries on R1’s left and right coccyx on or about 06/11/2020. R1 received care for the pressure injuries from the home health agency (HHA) during the period 06/11/2020 – 07/13/2020. Staff were instructed by the HHA to reposition R1 every two hours and to only allow a supine position during R1’s meals. On 07/13/2020, the HHA indicated both pressure injuries had healed and the visits by HHA skilled nursing staff would cease. Facility staff were instructed to rotate R1’s position every two hours to ensure proper skin perfusion and avoid future injuries. Staff were also instructed to notify the HHA if a new pressure injury occurred. On 07/23/2020, staff notified the administrator that R1’s coccyx pressure injuries had returned and needed skilled nursing care. Copies of texts provided by the administrator showed the administrator contacted the HHA on 07/23/2020 and requested they come back to the facility to provide pressure injury treatment. The HHA notified the administrator that R1’s insurance company had not approved them to provide further care for R1. On 07/24/2020, texts between the administrator and HHA showed the HHA representative sent an example of the type of pressure injury care supplies needed for R1. The administrator inquired if R1’s insurance company approved the HHA to return to the facility to provide care and the HHA informed the administrator they had not received approval yet; the HHA indicated approval can take days to weeks. On 07/30/2020, texts between the administrator and HHA representative showed the HHA was still awaiting approval from the insurance company and the administrator indicated R1’s pressure injuries were worsening and turning black. The HHA representative indicated the pressure injuries should have healed if staff were repositioning R1 every two hours as instructed. The HHA said R1 should only be in a supine position for meals. On 08/01/2020, texts showed the administrator notified the HHA representative that R1’s insurance company approved HHA pressure injury care. This was on a Saturday and the HHA informed the administrator the HHA on-call staff were notified, and she should also follow up with the HHA on Monday, 08/03/2020. (continued on 9099-C) In a text between the administrator and the house manager on 07/30/2020, the administrator informed the house manager that she called the HHA, but they still did not receive an order to provide care for the pressure injuries. The administrator said in the text a nurse informed her she could take R1 to the hospital emergency department, however R1’s Power of Attorney (POA) did not want her to do that out of COVID concerns. In addition, R1 was difficult to transport due to aggressive behaviors and would be difficult to manage in the hospital waiting area. The administrator instructed the house manager to have staff sit in R1’s room and do their best to distract R1 from turning into a supine position after being repositioned. On 08/01/2020, the house manager texted the administrator notifying her that R1’s pressure injuries were getting worse. The HHA came to the facility on 08/03/2020 to assess R1’s pressure injuries. The pressure injuries were observed to have become one large pressure injury. The HHA nurse did not note the pressure injury stage, but did take a photograph and measured the pressure injury at 6 cm X 6 cm. The HHA nurse also photographed another pressure injury on R1’s right lower leg. An appointment with R1’s physician was made for 08/05/2020. On 08/05/2020, R1 was transported to the medical appointment by a medical transportation service. R1’s physician sent R1 to the hospital due to the pressure injury on R1’s coccyx. R1 was admitted to the hospital on 08/05/2020 due to the Stage IV sacral decubitus ulcer with osteomyelitis and sepsis secondary to the sacral ulcer infection. On 08/07/2020, R1 had debridement of the sacral decubitus ulcer including sacral bone which measured 110 square centimeters. On 08/10/2020, R1 required another surgery for debridement of the sacrum ulcer including the bone measuring 25 square centimeters with laparoscopic sigmoid colostomy. (continued on 9099-C) In regard to the allegation that staff neglect led to Resident #1 (R1) sustaining a pressure injury, during HHA visits to the facility to provide pressure injury care for R1 from 06/11/20 – 07/13/20, facility staff were instructed to reposition R1 frequently, at least every two hours, and not allow R1 to stay in a supine position. In addition, R1 suffered from bladder and bowel incontinence. There were no facility records to show staff had a schedule to frequently check R1 for incontinence care or repositioning. According to the HHA, R1’s pressure injuries should not have worsened if staff were ensuring proper repositioning. The administrator and staff failed to ensure R1 was provided proper incontinence care or repositioning to allow the area with healed pressure injuries to worsen to the point of a Stage IV sacral decubitus ulcer developing. Based on medical records and other documentation obtained and reviewed, the allegation is deemed Substantiated at this time. For the allegation of staff neglected to seek timely medical attention for Resident #1 (R1), it was determined on or about 07/22/2020, the administrator and facility staff were aware R1’s coccyx pressure injuries had redeveloped and needed care by a skilled professional. On 07/24/2020, the HHA notified the administrator that insurance company approval for HHA pressure injury care could take days to weeks. Records show the administrator failed to seek other timely medical care by taking R1 to the hospital and allowed the pressure injuries to continue to worsen. R1 was not seen by the HHA nurse for 13 days and did not see a physician for 15 days after the pressure injuries were noticed, which was when R1 was finally sent to the hospital’s emergency department. Based on medical records and other documents obtained and reviewed, the allegation is deemed Substantiated at this time. A $500 immediate civil penalty shall be assessed at a later date. Due to technical difficulties the LPA was unable to issue the civil penalty during today's visit. The Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f). Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D). Exit interview conducted, civil penalty issued, appeal rights discussed, and a copy of this report issued.the state’s words, verbatim · CDSS document, Jun 8, 2022 · control 29-AS-20200805152818

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(a) · Plan of correction due date: Jun 15, 2022

§1569.312 Basic services requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2 This requirement is not met as evidenced by: Based on interviews and records reviewed, the licensee did not comply with the section cited above. Licensee failed to provide adequate care and supervision to R1 which attributed to R1 sustaining pressure injuries not reported and not properly cared for, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 8, 2022

Plan of correction: Licensee will submit plan to provide a proper level of care and supervision to ensure resident needs are met. Submit to CCL by 06/15/2022. An immediate civil penalty of $500 is warranted in accordance with California Health and Safety Code Section 1548(c)(1). However, due to technical difficulties the penalty must be issued at a later date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Jun 15, 2022

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on interviews and records reviewed, the licensee did not comply with the section cited above. Licensee failed to arrange for immediate and necessary care to R1’s pressure injuries resulting in R1’s pressure injuries worsening, which posedthe state’s words, verbatim · CDSS document, Jun 8, 2022

Plan of correction: Licensee will submit plan to arrange for medical care when necessary to ensure resident needs are met. Submit to CCL by 06/15/2022. an immediate health and safety risk to residents in care.

Allegation investigated: Staff neglect led to Resident #1 (R1) sustaining pressure injuries Staff neglected to seek timely medical attention for Resident #1 (R1)

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint visit to deliver an amended report. LPA met with administrator Ivy Sudjati and explained the reason for the visit. On 6/3/2022, this report was issued in error under the incorrect complaint number. The report was re-issued on 6/8/2022 under the correct complaint number 29-AS-20200805152818. (continued on 9099-C) Unfounded On 6/3/2022, this report was issued in error under the incorrect complaint number. The report was re-issued on 6/8/2022 under the correct complaint number 29-AS-20200805152818. (continued on 9099-C) On 6/3/2022, this report was issued in error under the incorrect complaint number. The report was re-issued on 6/8/2022 under the correct complaint number 29-AS-20200805152818. (continued on 9099-C) On 6/3/2022, this report was issued in error under the incorrect complaint number. The report was re-issued on 6/8/2022 under the correct complaint number 29-AS-20200805152818. (continued on 9099-C) On 6/3/2022, this report was issued in error under the incorrect complaint number. The report was re-issued on 6/8/2022 under the correct complaint number 29-AS-20200805152818. Exit interview conducted and a copy of this report issued.the state’s words, verbatim · CDSS document, Jun 3, 2022 · control 29-AS-20210519135621

From the deficiency page — Deficiency type: Type B · Section cited: CCR 000000000 · Plan of correction due date: Jun 10, 2022

None Nonethe state’s words, verbatim · CDSS document, Jun 3, 2022

Plan of correction: None None

From the deficiency page — Deficiency type: Type B · Section cited: CCR 0000000000 · Plan of correction due date: Jun 10, 2022

None Nonethe state’s words, verbatim · CDSS document, Jun 3, 2022

Plan of correction: None None

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Angel Ascencio arrived at the facility unannounced to conduct a required annual visit at 2:20 PM. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Ivy Sudjati and Allan Santos and discussed the reason for the visit. The LPA, along with Administrator, toured the physical plant areas inside and outside at 2:40 p.m. to ensure there are no health and safety hazards. Entrance interview conducted. BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 5 total bedrooms – two (2) bedrooms are shared rooms, two (2) bedrooms are private rooms and one (1) room is for staff. RESTROOMS: Three (3) restrooms for resident use were observed to be clean and sanitary and in operating condition. The bathrooms and showers were also observed to have grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap and paper products in each restroom, as well as hand washing posters. Water temperature was tested and was within normal ranges. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, common seating area and dining room furniture was observed to be in good condition. Chairs were observed to be at least 6 (six) feet apart for social distancing. The LPA observed the required postings in the common hallway. Fire extinguishers were observed to be serviced within the last year. Smoke detectors and carbon monoxide was observed to be in operable condition at the time of visit. The backyard has a covered area equipped with furniture for resident use. There are no bodies of water noted. Laundry room contained locked storage area for laundry supplies. Medication was observed to be locked and contained at least a 30-day supply. Continued on LIC 809-C. KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Water temperature was observed to be within normal limits. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit. INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices at 3:10 p.m. There is one (1) entry into the facility. Upon entry, the facility has a central point for symptom screening. LPA noted that the facility is allowing visitors for both indoor and outdoor visitation. The LPA observed an adequate supply of Personal Protective Equipment (PPE) and is able to obtain more if needed The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate. The following recommendations were made: - Post PINs and educate staff, residents, and families on changing policies and procedures from the Department - More COVID -19 Posters throughout the facility No citations were issued today's visit. Exit interview conducted. Copy of the report provided to Admin via email.the state’s words, verbatim · CDSS document, Mar 28, 2022

Allegation investigated: Resident sustained multiple injuries while in care. Facility did not provide food and/or liquid in the quality or quantity necessary to meet resident's needs

Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent complaint visit to deliver findings for the above allegations. The initial complaint visit was conducted on 05/19/2021 by LPAs Angel Ascencio and Zabel Chochian. During today’s visit, LPA Ascencio met with Allan Santos and explained the reason for the visit. On 05/19/2021, the Department received a complaint regarding allegations of Neglect/Lack of Supervision. It was alleged that Resident #1 (R1) sustained multiple pressure injuries while in care and the facility did not provide food in the quality or quantity necessary to meet R1’s needs. The complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Lorraine Patterson. Continued on LIC 9099 - C Unsubstantiated On 05/19/2021, at 2:09pm, LPAs Ascencio and Chochian conducted the initial complaint visit and met with Ivy Sudjati, Administrator. Between 2:09pm and 3:40pm, the LPAs toured the facility with the Administrator, reviewed resident records, interviewed the Administrator, and obtained copies of pertinent documents relevant to the investigation. The LPAs informed the Administrator that the complaint allegations required further investigation and the complaint was forwarded to the Investigations Branch (IB) for review. Investigator Patterson conducted interviews with the reporting party on 06/15/2021, at approximately 10:37am; with facility staff and residents on 10/26/2021, from approximately 1:48pm to 3:13pm; with Licensee/Administrator on 10/27/2021, at approximately 9:56am; and with Mission Hospice on 11/01/2021, at approximately 2:07pm. Investigator Patterson was unable to contact R1’s Gastroenterologist, despite multiple attempts. Information obtained through interviews revealed that R1’s representative, who was the durable power of attorney, refused the standardized tube feeding formula and made their own formula using unpasteurized raw cashews, almonds, sunflower seeds, and fruits to blend liquids and food for R1. R1 had a G-tube and had difficulty swallowing and the G-tube was needed for nutrition. R1 was immunocompromised and at a higher risk for food borne illness and the use of unpasteurized food put R1 at a higher risk and was not recommended. R1 had been frequently hospitalized for inadequate nutrition. R1’s representative was adamant on this type of feeding and required the facility to provide the blends created. R1’s representative was resistant to nutrition education. R1 had lost weight on this nutrition plan and continued to have severe malnutrition. Investigator Patterson reviewed documents including R1’s facility file, advance medical directives, communication emails between specialists, and medical/hospice/palliative records. Per R1’s Physician Report dated 12/29/2020, the primary diagnosis was listed as Dysphagia with chronic g-tubes. R1’s special diet was listed as administration of tube feeds, Kate Farm, bolus feeding, dysphagia diet. R1’s secondary diagnosis was listed as Hypertension and PAFIB. The report also listed R1 had a history of skin breakdown, was non-ambulatory and bedridden due to physical condition. R1’s illness also included fragility and poor nutrition; physical health status was fair; and R1 required home health physical and occupational therapy. Continued on LIC 9099-C Mission Hospice records listed the hospice certification and plan of care certification period for R1 as 03/20/2021 through 05/28/2021. R1 was admitted to hospice for End Stage Heart Disease. Nutritional requirements of the plan stated nothing by mouth, puree fruit through G-tube only as tolerated. The Kate Farms standard formula G-tube feedings were recommended, ordered and attempted, however, R1’s dysphagia worsened. R1’s representative insisted R1 try to eat fruits and nuts. The hospice Dr. agreed with the family’s request and it was approved that R1’s food be liquified into the G-tube based on but not limited to R1 not being able to tolerate anything else. The St. John’s Regional Medical Center (SJRMC) medical records revealed R1 was admitted to the ER on 04/17/2021 due to low blood pressure. R1 was discharged with diagnosis of Hypokalemia, Endophthalmitis and transferred to UCLA. While at UCLA, R1 had a speech therapy assessment. R1 was noted as too lethargic for oral intake and posed a high risk for aspiration. The speech therapist contacted the Dr. who requested R1 receive nothing by mouth or via tube until electrolytes balanced out. Additionally, the Dr. requested that R1’s representative bring in the tube feeding formula for R1 and not a homemade smoothie. On 04/18/2021, it was noted R1 had blanchable redness on coccyx present on admission along with a skin tear to upper thigh. R1’s discharge diagnosis was septic shock; urinary tract infection; hypovolemic hyponatremia; hypokalemia; hypophosphatemia; dehydration; toxic metabolic encephalopathy and severe protein calorie malnutrition. R1 was admitted again to SJRMC on 05/15/2021 with a chief complaint of abdominal pain. During the exam, R1 was noted to have a pressure injury on sacrum and heels, unstageable Upon evaluation, R1 had a high probability of imminent or life-threatening deterioration. R1 was assessed Code Blue and CPR given. All medical professionals in the room agreed to stop the code and stated no further ideas for intervention. R1 died on 05/16/2021 at 7:32pm with the preliminary cause of death as septic shock, urinary tract infection. There were no abuse or neglect concerns noted in the emergency department records. Continued on LIC 9099 - C On the allegation: Neglect/Lack of Care and Supervision - Facility did not provide food in the quality or quantity necessary to meet Resident #1 (R1) needs. Investigator Patterson obtained and reviewed medical/hospice/palliative records and the facility file for R1. In addition, Investigator Patterson interviewed staff, residents, hospice, and medical professionals. R1 was admitted to the hospital on 05/15/2021 with a diagnosis not limited to dehydration and severe protein calorie malnutrition and R1’s representative was adamant with providing R1 with homemade blends over a standardized tube feeding which was not recommended. R1’s representative required the facility staff to feed R1 home blends which placed R1 at a higher risk for food borne illness due to R1 was immunocompromised. R1 had a terminal diagnosis of 6 months or less. R1 was prescribed nothing by mouth (NPO), suffered severe food allergies, poor nutrition and hydration. R1 was only able to tolerate limited foods. R1 was a full code. R1 was on and off hospice and palliative care when aggressive/elective care was needed. R1’s representative was the durable power of attorney and guided the family towards aging and R1’s diet. Facility staff reported the care provided R1 was congruent to the plan of care and as doctors recommended. The information and evidence obtained during the investigation did not sufficiently support the allegation, therefore the allegation is deemed Unsubstantiated at this time. Exit interview conducted, and copy of report given provided to Admin via email.the state’s words, verbatim · CDSS document, Mar 9, 2022 · control 29-AS-20210519135621