Horizon Assisted Living Facility

Allegation investigated: It was alleged that Resident sustained multiple ulcer wounds while in care Staff did not seek timely medical care for resident.

Licensing Program Analyst (LPA) Tihesha Smith made an unannounced complaint visit to this facility at 10:10 am to deliver findings. LPA Smith met with facility staff and disclosed the purpose of this visit. The administrator was present at the facility. A 24-hour visit was conducted by Licensing Program Analyst (LPA) Tihesha Smith on 06/30/2023, at which time LPA Smith conducted a physical plant tour at approximately 11:20 am and conducted an interview with the administrator. On 06/29/20223 this case was referred to the Community Care Licensing Investigations Branch (CCIB). Investigator Christine Ferris continued the investigation by conducting records review and interviews on 08/01/2023, 08/04/2023, and 08/30/23. (Cont to 9099C) Substantiated (Cont from 9099A) Staff did not ensure resident was hydrated. It was alleged that due to severe dehydration R1’s health condition got more complicated. Staff revealed that they keep resident hydrated at all times. Between 06/23/23 and 06/25/23 R1 was having swallowing difficulties but was able to intake fluids. Staff informed hospice services and staff also spoke to R1’s responsible party, who called 911. A review of hospice records revealed that R1 ate and drank regularly. R1 was assessed for hydration during skilled nursing visits and there were no signs of dehydration. Other witnesses interviewed during investigation revealed that they saw a “two-liter bottle” of water by R1. Due to finding no evidence to suggest fluids were withheld or any actions or lack thereof by staff contributed to R1s dehydration, there is not sufficient information to support the allegation, Therefore, the above stated allegation is determined to be unsubstantiated at this time. Staff did not observe a change in resident's condition It was alleged that Staff did not observe a change in R1s condition. Interviews with staff on 06/30/23, 10/31/2023, and interviews conducted during the course of the investigation reveal that staff noticed R1’s wounds not healing. Staff revealed that as of 06/14/2023, they noticed that R1 was having swallowing difficulties and developed prohibited health conditions, posing immediate danger to R1’s health and safety. Based on interviews and records review staff monitored R1s condition and noticed changes in R1s condition consequently there is insufficient information to support the allegation. Therefore, the above stated allegation is determined to be unsubstantiated at this time. Exit interview conducted/Appeals/Copy of report given. (Cont from 9099) It was alleged that Resident sustained multiple ulcer wounds while in care. Staff interviews conducted on 08/01/2023, revealed that upon admission to the facility, staff assisting Resident #1 (R1) noticed a black bloody spot on R1’s coccyx. The spot felt hot like it was burning. Staff was repositioning and turning R1 every 2 hours. Interviews also revealed that although a “small, black spot” was noticed near R1’s coccyx, staff did not know “what was under the tissue,” but it was “deep when the skin opened on 06/13/2023”. A review of hospice/palliative and wound care records conducted by the IB investigator revealed that while in care at the facility, R1 developed pressure injuries. As of 06/13/2023, the pressure injuries were staged as Stage 4. Although R1 was receiving wound care by medical professionals between 06/13/23 to 06/25/23, the conditions of the wounds got worse. Records revealed that a sacral stage 4 pressure injury was addressed and subsequently treated by the wound specialist. However, other Stage 4 pressure injuries noted in hospice records, were not addressed by medical professionals. IB investigators review of the hospital records revealed,that on 06/27/2023, R1 was admitted to the hospital with multiple Stage 4 pressure injuries on sacrum, Stage 4 pressure injuries on the left and right buttock. R1 was diagnosed with sepsis (secondary to the buttock wound infection). In addition, R1 had several deep tissue pressure injuries. Overall, the investigation revealed that although facility staff including the Administrator had knowledge that R1’s pressure injuries were not healing, they failed to obtain all required information from the hospice agency and take appropriate measures to ensure that there is no immediate threat to the health and safety of the resident. Based on the information revealed from interviews and records review, there is sufficient information to support the above stated allegation. Therefore, the allegation is determined to be Substantiated at this time. Staff did not seek timely medical care for resident. It was alleged that R1’s overall health condition was declining, and staff failed to provide emergency medical assistance on time. Staff revealed that as of 06/14/2023, they noticed that R1 was having swallowing (Cont to 9099C) (Cont from 9099C) difficulties and developed prohibited health conditions, posing immediate danger to R1’s health and safety. Staff admitted not contacting emergency services. Between 06/14/2023 and 06/27/2023 R1’s condition got worse. R1’s responsible party was contacted, and 911 was called by R1’s responsible party. A review of the medical records verified the information received from the staff. Based on the information revealed from interviews and records review, there is sufficient information to support the above stated allegation. Therefore, the allegation is determined to be Substantiated at this time. Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, Oct 31, 2023 · control 31-AS-20230629104943

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Nov 2, 2023

Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement was not met as evidenced by: Based on record reviews & interviews, R1 wounds not healing, developed unstageable wounds while in care which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 31, 2023

Plan of correction: Licensee shall submit a written plan describing how the facility shall prevent injuries to residents in care as a result of this deficiencies. Licensee shall submit to CCL no later than 11/02/2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Nov 2, 2023

87465(g) Incidental Medical and Dental Care. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health This requirement was not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited, as staff did not seek medical attention for R1 in a timely manner, which posed an immediate health and safety risk to R1the state’s words, verbatim · CDSS document, Oct 31, 2023

Plan of correction: The Administrator agreed to do the following: Submit a Statement of Understanding, and the steps the facility will take to avoid similar issues from happening and to ensure compliance to the cited regulation Licensee shall submit to CCL no later than 11/02/2023

The state marks this report as 7 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Allegation investigated: Facility staff failed to provide resident's records to an authorized representative

Licensing Program Analyst (LPA) Tihesha Smith conducted an initial complaint visit to this facility at 10:30 am. LPA Smith met with facility staff and disclosed the purpose of the visit and the administrator arrived later. It was alleged that Facility staff failed to provide resident's records to an authorized representative. LPA Smith conducted physical plant tour at 10:50 AM, interviewed administrator at 11:00 am. Interview with the administrator revealed she did not receive a FedEx letter for R1s records. The administrator revealed she was contacted by telephone on 04/27/23 at 10:24 am from the corporate office requesting R1s records and she sent over 85 pages of records the same day. LPA Smith reviewed the administrators call history and the fax transmittal page dated 04/27/23 indicating 93 pages were sent to the corporate office. LPA Smith also contacted the corporate office at 11:52 am but was unable to get verbal confirmation that the records were received. Based on the information gathered during this visit, the allegation is deemed unsubstantiated at this time. No citations issued. Exit interview conducted. Copy of this report issued Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 28, 2023 · control 31-AS-20230421131329

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Tihesha Smith conducted an unannounced Required 1-year inspection at this facility 11:55 am. LPA disclosed to the administrator the purpose of the visit. LPA conducted a tour of the physical plant at approximately 11:56 am to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. Common areas were observed for the ability to safely serve the needs residents. These included the kitchen/dining room combination, living room and family room. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed to be furnished appropriately with adequate seating for residents. LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The kitchen food supply was observed and sufficient for the six (6) residents currently residing there. Two (2) days of perishable food observed. The freezer is stocked with meats and frozen vegetables. Emergency food pantry in hall closet. Sharps are stored in locked bottom kitchen cabinet. The resident medications stored in locked top kitchen cabinet and observed to be inaccessible to residents. The first aid kit and manual readily accessible on counter below medication storage. There is one (1) fire extinguisher attached to wall in the kitchen and observed to be charged. Laundry room is located adjacent to kitchen. The appliances observed to be functional. Toxins stored above in locked cabinet above washer and dryer was observed to be locked and inaccessible to residents. (Cont from 809) The facility has a total of five (5) bedrooms and four (4) bathrooms: One (1) shared and four (4) private bedrooms; three (3) bathrooms for residents use and one (1) bathroom for staff. The resident bedrooms were properly furnished with at least one chair, night stand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed a supply of linens in hall closet. Each bathroom has posted “wash your hands” signs and the following items available: hand soap, paper towels, and trash cans. The hot water temperature was measured for the three (3) bathrooms to ensure it is within the required range for residents’ comfort and safety. The water temperature range was between 110.5, 112.6 and 113.5 degrees Fahrenheit. Backyard has the following: Gazebo with sufficient seating for the residents. Patio furniture observed to be in good repair. Detached Garage: Used for PPEs and storage. Smoke detectors/carbon monoxide detector were tested and operable at time of visit. Facility grounds were free of hazards. There were no immediate health and safety hazard observed during the day of inspection. At approximately 12:45 pm, LPA reviewed files for the six (6) residing residents. Resident files included medical assessments and needs and services plans. Staff files reviewed for three (3) staff. Staff files had the appropriate training's to include Dementia, Hospice, and First aid/CPR. No deficiencies cited. Exit Interview Conducted / A Copy of the Report Issued.the state’s words, verbatim · CDSS document, Apr 28, 2023

Allegation investigated: Neglect Lak of Care and Supervision. Resident 1 (R1) developed multiple Unstageable Pressure Injuries while in care.

An unannounced subsequent complaint visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan. Upon arrival, the LPA met with staff Rosa Tonoyan, who contacted administrator Sona Gevorkyan via telephone. Approximately 1:00 pm Ms. Gevorkyan arrived to the facility. Upon arrival LPA conducted a brief tour of the facility and spoke with Staff. While conducting the tour LPA observed the 2 backyard gates exiting the facility pad locked. 1 of the 2 gates is not used as an exit. Regarding the allegation listed above, concerns of Neglect/Lack of Care resulting in Resident 1 (R1) developing multiple pressure injuries while living at the facility were reported. This investigation was conducted by Olivia Spindola, Investigator with Community Care Licensing Division’s Investigations Branch (IB) and Licensing Program Analyst (LPA) Yelena Avetisyan. Continued on 9099 (c) Substantiated On various days from 05/14/2020 to 07/08/2020 Investigator Spindola conducted interviews with facility residents, staff, administrator and other relevant parties. Additionally, on 5/28/2020 and 6/15/2020 Investigator Spindola conducted review of Medical Records from All Saints Hospice subpoenaed on 5/14/2020 and Northridge Hospital subpoenaed on 5/12/2020. On 3/16/2022 LPA Y. Avetisyan requested Discharge Records for R1 from Casitas Care Center. The records were received on 3/23/2022. On 4/11/2022 LPA Avetisyan issued a second subpoena to All Saints Hospice to obtain complete hospice records for R1. . Records were received on 4/12/2022, 4/14/2022, 4/21/2022. Due the agency not submitting all records as requested in the subpoena LPA requested records to be prepared for pick up along with custodian of records documentation. The records were picked up on 5/22/2022 however Custodian of records confirmation was not provided. From 4/14/2022 to 4/25/2022 LPA conducted various email communication with All Saints Hospice Agency staff to clarify information documented in the records. When interviewed on 5/14/2020 and 6/15/2020 the Administrator stated that R1 was admitted to the facility on 02/20/2020 and hospitalized on 4/23/2020 due to trouble breathing. Per administrator R1 was living at the facility with hospice care after hospitalization as a result of several medical conditions including but not limited to multiple pressure injuries on back, heels, and buttocks. However, review of discharge records from Casitas Care Center did not indicate R1 having any pressure injuries. Discharge body check documented discoloration on the arms and redness on the thigh/groin. Review of hospice records revealed various inconsistencies between the documents obtained during the initial 10 day complaint visit, provided to Investigator Spindola and LPA Avetisyan. The 4/22/2020 RN visit record documented Head to toe Assessment performed. Vital signs were checked. Patient has pressures on Left Buttocks area, Mid lower back. Northridge Hospital medical records documented the following pressure injuries upon hospitalization. DTPI Left hip, Unstageable, left flank/back Upper back multiple DTPI wounds, Unstageable Sacrum-extending to bilateral buttocks , LLE skin tear with underlying hematoma vs DTPI, Unstageable Midback pressure injury, DTPI Right dorsal foot, Right medial foot and Right Posterior calf DTPI. Information obtained during the course of the investigation revealed that upon discharge from Casitas Care Center R1 did not have any medical documentation that included a diagnosis of pressure injuries. Licensee did not complete pre-placement appraisal or appraisal identifying pressure injuries upon admission. Hospice and Hospital records confirmed R1 developed multiple unstageable pressure injuries and Deep tissue pressure injuries while living at the facility therefore the allegation of Neglect/Lack of Care and Supervision is Substantiated. Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.the state’s words, verbatim · CDSS document, Jun 25, 2022 · control 31-AS-20200428160827

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87611(c) · Plan of correction due date: Jun 27, 2022

In addition to Section 87411(d), facility staff shall have knowledge and the ability to recognize and respond to problems and shall contact the physician, appropriately skilled professional, and/or vendor as necessary. This requirement was not being met as evidenced by: Based on Information obtained during the course of the investigation the facility staff did not comply with the cited section by not having knowledge and ability to properly document respond and obtain medical care of R1's various pressure injuries not being treated by the hospice agency which posed an immediate health and safety, and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Jun 25, 2022

Plan of correction: Licensee/Administrator will submit a Detailed written explanation why they have been continuously operating non-compliant as evidenced by the various complaints received by the department. Licensee/Administrator will also need to submit a detailed plan regarding the steps that will be taken to ensure compliance of all deficiencies issued since licensure. Licensee/Administrator will also provide in service training to all staff regarding the cited. Certification of the training will need to be submitted as POC.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Jun 27, 2022

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. This requirement was not met as evidenced by. Based on information obtained during the course of the investigation the licensee/ administrator did not comply with the cited section by not having knowledge of R1's various pressure injuries not being treated by hospice and ensuring proper medical care was obtained prior to hospitalization which posed an immediate health and safety, and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Jun 25, 2022

Plan of correction: Licensee/Administrator will submit a Detailed written explanation why they have been continuously operating non-compliant as evidenced by the various complaints received at the department. Licensee/Administrator will also need to submit a detailed plan regarding the steps that will be taken to ensure compliance of all deficiencies issued since licensure. This is a repeat citation therefore civil penalty in the amount of $250 dollars has been issued, civil penalty will continue to accrue until plan of correction is submitted to the LPA. First citation issued on 4/7/2022.

Type of visit: Case Management - Annual Continuation

An unannounced case management Annual Continuation visit in conjunction with a subsequent complaint visit (Complaint Control # 31-AS-20200428160827) was conducted on this day by licensing program analyst (LPA) Yelena Avetisyan. Upon arrival, the LPA met with staff Rosa Tonoyan, who contacted administrator Sona Gevorkyan via telephone. Approximately 1:00 pm Ms. Gevorkyan arrived to the facility. Approximately 12:37 pm LPA conducted a brief tour of the facility and spoke with Staff. While conducting the tour LPA observed the 2 backyard gates exiting the facility pad locked. When touring the facility LPA observed R1 in Rm # 2 utilizing full bed rails. When asked staff stated that they currently have 4 residents on hospice. From 2:20 pm LPA conducted review of files for 5 residents. LPA requested to review hospice files for residents however licensee did not have complete hospice files for 4 out of 4 residents who are currently receiving hospice services Licensee did not have hospice care plan for R1 indicating the need for the full rail. A discussion was held with the administrator about ensuring that a complete hospice file is kept at the facility along with copies of hospice visit reports. At 4:00 pm LPA conducted review of staff files. While reviewing the staff files LPA observed that licensee/administrator is not documenting staff training properly. Staff 1 does not have medication training since start of employment. Staff #2 received medication training from a hospice RN however the licensee/administrator did not have copy of the test taken, or information regarding the training program that was used to provide the training. Staff 3's medication training was from 2019 and documentation missing same information/documentation as staff 2. A lengthy discussion was held with Ms. Gevorkyan regarding documenting staff training, and the requirements of medication training. From approximately 5:12 pm LPA observed as staff provided assistance to R1. LPA observed R1 required the assistance of 2 staff to sit up in bed, stand from bed and required physical assistance by staff to sit on the wheelchair and reposition body to be able to sit on the wheelchair. Based on LPA observations resident appears to be bedridden and currently residing in a room that has ambulatory fire clearance. LPA requested the following documents to be submitted to the Woodland Hills RO by 6/27/2022 Initial/Comprehensive Hospice Assessment for all 4 residents. Administrator will also work with the hospice agency to obtain and retain complete and up to date hospice files for all residents at the facility. To ensure hospice care plan for R1 specifies the need for the full rails. Documentation regarding the medication training provided to Resident by Hospice RN. The administrator understands if the training provided was not compliant with the regulations she will schedule vendorized medication training for all staff. Copy of current liability insurance Current LIC 500. Exit interview conducted, copy of report, citations and civil penalties issued.the state’s words, verbatim · CDSS document, Jun 25, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(I)(5) · Plan of correction due date: Jun 26, 2022

The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates. This requirement is not being met as evidenced by Based on observation and interview the licensee did not comply with the section cited by locking the backyard exit doors/gates of the facility without the approval of the fire department which poses an immediate health and safety and personal rights violation to persons in care.the state’s words, verbatim · CDSS document, Jun 25, 2022

Plan of correction: Staff removed the locks from the gates. Licensee/administrator will submit a dated and signed written statement that exit doors will not be pad locked at any time. This is a zero tolerance violation therefore a civil penalty in the amount of $500.00 has been issued. Civil penalties will continue to accrue until plan of correction is submitted.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87202(a)(2) · Plan of correction due date: Jun 26, 2022

FIRE CLEARANCE. All facilities shall maintain a fire clearance. Prior to accepting persons over 60 years of age none ambulatory and/or bedridden the licensee shall notify the licensing agency and obtain an appropriate fire clearance. This requirement is not met as evidenced by: This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited by retaining bedridden resident in room with non ambulatory fire clearance (R1)which poses an immediate health, safety and personal rights risk to R1.the state’s words, verbatim · CDSS document, Jun 25, 2022

Plan of correction: Licensee/Administrator will submit a dated, signed written statement notifying the department how this deficiency will be corrected. This is a zero tolerance violation therefore civil penalty in the amount of $500 has been issued. Civil penalties in the amount of $100 dollars per day will accrue until POC is received.

Allegation investigated: Resident's needs are not being met. Staff speak inappropriately to resident.

Licensing Program Analysts (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility. Upon entry, LPA met with the administrator, Sona Gevorkyan, and explained the reason for the visit. --- Resident’s needs are not being met. It was alleged that the resident is deteriorating fast. To investigate this allegation, on 06/01/2020, LPA Martina Berry interviewed staff, responsible party and complainant. On 06/08/2022, LPA Abeye Duguma interviewed residents and requested the resident’s file. Interviews and record review revealed that staff are meeting the needs of Resident #1 (R1), that R1 suffered from a stroke and was diagnosed with dementia which can alter behavior as the resident’s health deteriorates. Based on interviews and record review, the allegation is unsubstantiated at this time. (cont. on LIC9099-C) Unsubstantiated --- Staff speak inappropriately to resident. It was alleged that staff are verbally abusive. To investigate this allegation, on 06/01/2020, LPA Martina Berry interviewed staff, responsible party and complainant. On 06/08/2022, LPA Abeye Duguma interviewed residents. Interviews revealed that staff are treating residents well, staff are not treating residents inappropriately and that staff are not verbally abusive towards residents. Based on interviews, the allegation is unsubstantiated at this time. No other deficiencies were noted during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Jun 8, 2022 · control 31-AS-20200521115717

Allegation investigated: Licensee/administrator failed to provide appropriate level of care and supervision which resulted in R1 sustaining multiple pressure injuries.

An unannounced subsequent complaint visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan. Upon arrival, the LPA met with staff .Svetlana Petrosyan and Volunteer Anush Danelyan. Ms. Petrosyan contacted administrator Sona Gevorkyan via telephone. LPA spoke with Ms. Gevorkyan who stated she is far from facility and would not be able to come for the visit. Ms. Gevorkyan designated Ms. Petrosyan to sign for the report. Regarding the allegation listed above, it is being alleged that the R1 was admitted to the hospital twice in less than one month. Upon the 03/23/2021 admission to the hospital, concerns of neglect were reported due to pressure injuries. This investigation was conducted by Douglas Real, Investigator with Community Care Licensing Division’s Investigations Branch (IB). On 5/12/2021, Investigator Real conducted a review of Kaiser Permanente medical records. Additionally, on various days from 05/12/2021 to 06/24/2021 Investigator Real conducted interviews with facility residents, administrator, staff, and other relevant parties. Substantiated The review of the records revealed the following: R1 was hospitalized on 03/23/2021. Upon admission, R1 was diagnosed with septic shock and acute organ dysfunction and diagnosed with unstageable pressure injury on coccyx, an unstageable pressure injury on left and right heels, deep tissue pressure injury on ischium, a stage III pressure injury (vs trauma) on the leg, deep tissue pressure injuries on the left and right hips, and a deep tissue pressure injury on the left lateral posterior back. Hospital records also documented that R1 was bed bound since sustaining a hip fracture 02/17/2021. Interviews conducted by Investigator Real revealed the following: Administrator and staff were not aware of R1 having pressure injuries prior to hospitalization; however, when interviewed the administrator recalled seeing some “bedsores” on R1’s back. According to the administrator, the pressure injuries were initially open but improved over time and closed. Administrator did not provide approximate time the pressure injuries were observed, or documentation related to the care of the pressure injuries. Additionally, Staff 1 (S1) recalled seeing an injury on R1’s buttocks but did not recall if it was open or closed. R1 received home health services from 02/26/2021 to 03/08/2021 however the services did not include wound care. Home health care staff did not identify pressure injuries. Information obtained during the course of the investigation revealed that R1 developed pressure injuries on or after 03/08/2021. R1 did not receive care for the pressure injuries from a physician or skilled medical professional until being hospitalized on 03/23/2021, therefore the allegation of neglect/lack of care and supervision is substantiated. Per California Code of Regulations (CCR), Title 22, see LIC 9099-D for deficiencies cited. An immediate civil penalty of $500 is also assessed. The licensee was informed that a civil penalty might be assessed based on the Health and Safety Code 1569,49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f). Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.the state’s words, verbatim · CDSS document, Apr 7, 2022 · control 31-AS-20210326092829

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Apr 8, 2022

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 RP This requirement was not met as evidenced by: Based on IB investigation record review and interview, the licensee/administrator did not comply with the cited section by not having knowledge of R1’s pressure injuries prior to hospitalization which posed an immediate health and safety and personal rights risk to R1the state’s words, verbatim · CDSS document, Apr 7, 2022

Plan of correction: Licensee/Administrator and all staff will attend vendorized training related to the cited sections. 1) Verification of the scheduled training with the credentials of the trainer will need to be emailed to the LPA by 4/9/2022 2) Verification of completed training will need to be submitted to the LPA by 4/19/2022. Licensee/Administrator will also submit a written statement notifying the department what steps will be taken to ensure compliance with cited regulation at all times.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87631(a)(3)(A) · Plan of correction due date: Apr 8, 2022

the licensee shall be permitted to accept or retain a resident who has a healing wound under the following circumstances:(3)Residents with a stage 1or2 pressure injury must have the condition diagnosed by a physician/appropriately skilled professional. (A)The resident shall receive care for the pressure injury from a physician/appropriately skilled professional. This requirement was not met as evidenced by: Based on IB investigation record review & interview, the licensee/admin did not comply with the cited section by not having R1's pressure injuries diagnosed & treated by a physician/appropriately skilled prof. Which posed an immediate health and safety risk to R1the state’s words, verbatim · CDSS document, Apr 7, 2022

Plan of correction: Licensee, Administrator will schedule 6 hours vendorized training for themselves and all staff related to the cited section as well as the following title 22 regulations. 87615, 87609, 87611, 87612, 87613. 1) Verification of the scheduled training with the credentials of the trainer will need to be emailed to the LPA by 4/9/2022 2) Verification of completed training will need to be submitted to the LPA by 4/19/2022. Licensee/Administrator will also submit a written statement notifying the department what steps will be taken to ensure compliance with cited regulation at all times.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f) · Plan of correction due date: Apr 9, 2022

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 was not met as evidenced by: Based on IB investigation record review and interview, the licensee/administrator failed to provide proper care and supervision by not having knowledge of R1's various pressure injuries, which due to neglect were diagnosed as prohibited health conditions upon hospitalization posed an immediate health and safety and personal rights risk to R1the state’s words, verbatim · CDSS document, Apr 7, 2022

Plan of correction: Licensee, Administrators will schedule 2 hours vendorized training for themselves and all staff related to the cited section. 1) Verification of the scheduled training with the credentials of the trainer will need to be emailed to the LPA by 4/9/2022 2) Verification of completed training will need to be submitted to the LPA by 4/19/2022. Because this violation resulted in resident developing prohibited health conditions as a result of improper care an immediate civil penalty in the amount of $500 is issued.

Type of visit: Case Management - Deficiencies

An unannounced Case Management Deficiencies visit in conjunction with a subsequent complaint visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan. The purpose of this visit is to address deficiency identified during today's visit that is not related to the complaint control 31-AS-20210326092829. Upon arrival, the LPA met with staff .Svetlana Petrosyan and Volunteer Anush Danelyan. Ms. Petrosyan contacted administrator Sona Gevorkyan via telephone. LPA spoke with Ms. Gevorkyan who stated she is far from facility and would not be able to come for the visit. Ms. Gevorkyan designated Ms. Petrosyan to sign for the report. While speaking with staff LPA requested the names for the 2 staff observed when entering the facility. Ms. Petrosyan provided her name and last name. LPA then asked for the name of the other individual Ms. Petrosyan stated that the person is a volunteer. The volunteer left the facility shortly after the LPA's arrival. While reviewing the complaint report prior to final printing Ms. Petrosyan was speaking on the phone with the administrator in Armenian. They were discussing the volunteer and status of her criminal record clearance. After the phone conversation ended LPA asked Ms. Petrosyan about the volunteer. At that time Ms. Petrosyan informed the LPA that Ms. Danelyan is not a volunteer, but is her personal assistant and does not provide assistance with residents. A discussion was held why her personal assistant is walking around the facility, near resident rooms. Approximately 6:10 pm LPA conducted interviews with 3 of the facility residents. When interviewed all residents confirmed that the volunteer has been working at the facility and providing them care for approximately a month. Residents interviewed also confirmed that Ms. Petrosyan and Ms. Danielyan started working at the facility "around the same time" Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited: (Refer to LIC 809-D). Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.the state’s words, verbatim · CDSS document, Apr 7, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Apr 8, 2022

Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility (1) Obtain a California clearance or a criminal record exemption as required by the Department . This requirement is not met as evidenced by Based on observation and interview the licensee/administrator did not comply with the section cited by allowing S2 to work at the facility prior to obtaining criminal record clearance which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 7, 2022

Plan of correction: Licensee/Administrator will ensure the staff member receives criminal record clearance prior to returning to the facility. Licensee/administrator will submit verification of Live scan and photo ID of volunteer who left the facility. This is a zero tolerance violation therefore a civil penalty in the amount of $500.00 has been issued. Civil penalties will continue to accrue until plan of correction is submitted.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87207 · Plan of correction due date: Apr 9, 2022

No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This Requirement was not met as evidenced by: Based on the information obtained by LPA during the visit the licensee/administrator and staff did not comply with he cited section by providing false/misleading statements to LPA regarding Staff/volunteer which posed an immediate personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Apr 7, 2022

Plan of correction: Licensee/Administrator designee will submit a written explanation to the department regarding their actions. Licensee/Administrator an all staff will also attend vendorized training for the following title 22 regulations. 87408: Denial or Revocation of a Certificate, 87777: Exclusions, Personal Rights 1) Verification of the scheduled training with the credentials of the trainer will need to be emailed to the LPA by 4/9/2022. 2) Verification of completed training will need to be submitted to the LPA by 4/19/2022.

Allegation investigated: Staff use postural supports to restrain residents.

Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced complaint visit to investigate the allegation above. LPA met with the administrator and explained the reason for this visit. Upon entry LPA conducted a physical plant tour from 9:45-10am to ensure no immediate health and safety issues. It is alleged that facility used postural supports inappropriately. It is alleged that staff use a gait belt on residents at night so they cannot move. LPA conducted interviews with residents from 10:45-11:30am. LPA conducted interviews with facility staff from 11:30-12pm regarding this allegation. LPA also reviewed resident files from 10:00-10:30am. Information revealed that resident #1 (R1) was prescribed a half bed rail but at night another half bed rail was put up in addition to the half bed rail R1 was already using. Based on the information obtained from record review and interviews this allegation is deemed Substantiated. Staff used half bed rail inappropriately. Deficiency cited on LIC 9099 D. Appeal Rights explained. Exit Interview conducted. Substantiated Staff did not meet resident's incontinence needs. It is alleged that facility staff would not assist resident #1 (R1) as needed when they needed to use the restroom. LPA conducted an interview with R1's responsible person, residents, and facility staff regarding this allegation. LPA was not able to interview R1 as R1 has moved out of the facility. Information from interviews reveal there is not enough information to state that R1 was not assisted as needed when needing to use the restroom. Therefore this allegation is deemed Unsubstantiated at this time. Resident not given medication as prescribed It is alleged that R1 was not given their prn medication as prescribed. LPA interviewed R1's responsible person regarding this allegation. LPA interviewed facility staff from 11:30-12pm. LPA reviewed R1's medication documentation from 12:30-1pm. A review of R1's medication revealed that R1 was to be given Lorazepam(one tablet every four hours) as needed for agitations. Based on information obtained through interviews and record review there is not enough information to state that R1 was not given their medication as prescribed. Therefore this allegation is deemed Unsubstantiated at this time. Exit Interview conducted.the state’s words, verbatim · CDSS document, Mar 22, 2022 · control 31-AS-20220321131259

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(5)(B) · Plan of correction due date: Mar 23, 2022

Postural support-Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement was not met as evidenced by: Based on interviews conducted facility used two half bed rails on R1's bed when they were sleep when only a half bed rail was noted to be used by physician which created a full bed rail. This posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 22, 2022

Plan of correction: Administrator will submit statement that all postural supports will be used as they are prescribed for. Statement will be sent to LPA.

Allegation investigated: Staff are mistreating a resident while in care

Licensing Program Analyst (LPA) Michael Cava conducted a complaint visit to this facility to investigate the above allegation. The investigation consisted of a physical plant inspection, interviews and record review. Per interviews and record review, the investigation reveals each resident interviewed had no complaints or concerns regarding facility service. The residents that were interviewed stated they are never mistreated by staff. Residents stated that they are also treated with respect. When residents were asked if they've ever witnessed any of their peers being mistreated, they all stated no. Interviews with staff also do not corroborate with the allegation. Review of Resident 1's (R1) record indicates some confusion/disorientation that may need some orientation. Based on the information obtained, there was insufficient evidence to confirm staff are mistreating a resident in care. Therefore, the allegation is deemed Unsubstantiated at this time. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 8, 2022 · control 31-AS-20220301141750

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Pitz conducted an unannounced infection control visit on this day. LPA was greeted upon entry and screened for COVID-19 symptoms by administrator. LPA toured the facility with administrator and confirmed that they do have an approved mitigation plan on file. LPA utilized the infection control domain of the RCFE inspection tool to verify that the facility was in compliance with various aspects of the mitigation plan, including but not limited to: screening visitors, having ample handwashing/ sanitizing supplies on site, having adequate PPE on site, having signs posted throughout the facility to remind residents and staff of various Covid precautions. LPA did not note any concerns at the time of visit. Report reviewed, signed and delivered. Exit interview conducted, no deficiencies cited.the state’s words, verbatim · CDSS document, Feb 24, 2022