JMP Care Home

Allegation investigated: Facility staff neglected Resident #1 (R1) Facility staff failed to seek timely medical attention for Resident #1 (R1)

Licensing Program Analyst (LPA) Stephanie Williams made an unannounced visit to the facility in order to deliver findings for the above allegations. LPA Williams identified herself to Administrator, Emelita Price, who was also informed of the purpose of the visit. The investigation consisted of records review and interviews with staff, residents, and witnesses. In regard to allegation #1, The Department determined, based upon investigation, that the facility staff failed to provide care and supervision to protect R1’s health and safety when during the course of R1 four year residence at facility, R1 sustained multiple injuries requiring medical attention as a result of what were identified as falls. During a fall on February 21, 2019, R1 sustained a left hip fracture which required surgery. On April 22, 2019, R1 sustained a right eye contusion as a result of a fall. Based upon review of Substantiated resident records, there was no indication following these falls, that facility implemented a plan of care to minimize R1’s risk for future falls. According to R1 facility records dated June 2020, R1 was “subject to fall” and required a walker for ambulation due to diagnosis of Paraparesis of both limbs. It was noted that facility staff will monitor. In addition, Staff #2 (S2) reported during the investigation that R1 had been showing decline in functioning and started walking slower; however, S2 reported that R1 refused to use walker. In addition, S2 told Department staff that S2 did not consult a doctor about R1 refusal for assistive devices. Despite staff observing change in R1’s condition, there was no indication again that facility implemented a plan of care to minimize R1’s risk for future falls. Furthermore, in September 17, 2020, due to what was identified as another fall, R1 was transported to the hospital and subsequently diagnosed with fracture of the cervical vertebrae. The allegation that, facility staff neglected R1, is substantiated. In regard to allegation #2, On 9/17/2020 at around 4:00 am, Staff #1 (S1) reported that they heard R1 get up to go to the bathroom. Then, R1 went back to R1 room but left the door open. S1 stated that this was very unusual for R1, so S1 decided to check on R1. When S1 entered the room, R1 was sitting on the floor with back leaning against the wall. S1 picked R1 up and put R1 back in bed. S1 reported no visible bruising or swelling to R1. However, S1 did not indicate if R1 was awake at the time of this incident nor was it indicated that S1 inquired with R1 as to R1’s condition immediately following the incident. S1 admitted to not reporting R1’s fall immediately to the facility administrator nor seeking medical attention or 9-1-1. S1 stated that at 11:00 am, R1 asked for assistance getting out of a chair and getting into bed. S1 stated that this was unusual for R1. S1 stated that R1 also complained of neck pain, which is when S1 decided to contact S2. It was reported that S2 arrived around 11:15 am. S1 had not called 9-1-1 prior to S2’s arrival even though S1 exhibited “unusual” behavior. S2 stated she found a “bump” on R1’s head and then called R1’s responsible party and 9-1-1. However, according to R1’s medical records, R1 was admitted into the hospital due to the fall, around 1:02 PM, approximately 9 hours after R1 initially fell. The allegation that, facility staff failed to seek timely medical attention for R1, is substantiated. Based upon the evidence discovered in the investigation, including interviews and records review, allegation that facility staff failed to seek timely medical attention for R1 is substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met. This posed an immediate Health and Safety risk to residents in care. See deficiencies cited on LIC 9099D. In addition, an immediate civil penalty will be assessed for violation resulting in injury. An exit interview was conducted where this report was discussed and a copy was provided to Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, Apr 14, 2022 · control 18-AS-20200928142900

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Apr 15, 2022

87468.2 Additional Personal Rights of ... (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (8) To be free from neglect, .... This requirement has not been met as evidenced by: Based on records review and interview, the licensee did not ensure that R1's personal right to be free of neglect. This is an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 14, 2022

Plan of correction: The licensee agreed to conduct training for all staff members on CCR 87468.2 and send proof to the department by POC date. Additionally, an immediate civil penalty is being assessed for not ensuring a care plan was in place for R1's fall prevention, which resulted in R1 sustaining a serious injury.

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

87465 Incidental Medical and Dental Care (g) 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 including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement has not been met as evidenced by: Based on records review and interview, the licensee did not ensure that R1 received timely medical attention. This is an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 14, 2022

Plan of correction: The licensee agreed to conduct training for all staff members on CCR 87465 and implement a protocol for staff members to identify imminent health threats to the residents. Proof to the department should be obtained by POC date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Stephanie Williams made an unannounced visit to the facility in order to conduct a case management visit. LPA Williams identified herself to Administrator, Emelita Price who was also informed of the purpose of the visit. On 9/30/2020, LPA Williams initiated a complaint investigation (Complaint Control #18-AS-20200928142900) and advised the Administrator that the investigation would be forwarded to the Department's Investigation Branch (IB). Upon completion of the investigation, Department staff identified that the facility had several violations that were not addressed in Complaint Control #18-AS-20200928142900. The following information was taken from the Investigative Case Report (RD #1820-09148): Resident #1 (R1) experienced multiple falls while residing at the facility. A Needs & Services Plan dated 6/24/20, indicated that R1 was "subject to fall." However, the facility did not have a specific plan in place to prevent falls. It was identified that R1 experienced several falls while residing at the facility; however, there was no evidence that the facility reported those falls appropriately. Staff #1 (S1) indicated to Department staff that they do not remember making the reports and they most likely did not report the falls. According to medical records, R1 was "covered" in bed bugs upon arriving to the hospital on 9/17/20. See deficiencies cited on LIC 809-D. An exit interview was conducted where this report was discussed and a copy was provided to the Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, Apr 14, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(5)(A) · Plan of correction due date: Apr 15, 2022

87705 Care of Persons with Dementia Licensees... ensuring the following: (5) shall include a reassessment of the resident’s dementia care... (A).. dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident. This requirement has not been met as evidenced by: Based on records review and interviews, the licensee did not ensure that corresponding changes were made to the care and supervision of R1. This is an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 14, 2022

Plan of correction: The Licensee agreed to conduct training for all staff members on CCR 87705 and also ensure that all residents have an updated care plan on file which reflects their current needs. Proof to the department should be obtained by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(D) · Plan of correction due date: Apr 21, 2022

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (D) Any incident which threatens the welfare, safety or health of any resident, ...this requirement has not been met as evidenced by: Based on records review and interviews, the licensee did not ensure that reports regarding R1's fall, which resulted in serious injuries, were sent to the Department appropriately. This is a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 14, 2022

Plan of correction: The Licensee agreed to conduct training for all staff members on CCR 87211 and send proof to the Department by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Apr 21, 2022

87466 Observation of the Resident - The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social ... When changes such as unusual weight gains or losses or deterioration of mental ability or a physical . This requirement has not been met as evidenced by: Based on records review and interviews, the licensee did not ensure that R1 was regularly observed for changes in physical condition. This is a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 14, 2022

Plan of correction: The Licensee agreed to conduct training for all staff members on CCR 87466 and send proof to the department by POC date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA)’s, Chinwe Nwogene and David Cuevas made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA's were greeted by Licensee, Emelita M. Price who was advice of the purpose of visit. At the time of visit there was 2 staff and 2 residents present. The facility currently has zero positive or suspected Covid-19 cases. LPA did not observe any pools or bodies of water within the premises. LPA were informed that no weapons or ammunition is maintained at the home. No annual fees due. During today's visit, LPA’s toured the facility and made observations regarding the infection control measures that the facility has implemented. LPA observed Covid-19 postings posted throughout the facility. The facility has an adequate amount of hand hygiene supplies (soap, hand sanitizer) in all restrooms (2 restrooms.) The facility has a plan in place to monitor residents regularly for any changes in condition, which includes daily temperature checks. The Facility will contact the resident's physician should there be event of any COVID-19 related illnesses. The facility also has a designated infection control lead and cleans and disinfects the highly touched surfaces during each shift, and as needed. LPA observed PPE supplies. During this visit mitigation plan was not on cite, per Licensee she will be email mitigation plan by 3/25/22, No deficiencies noted at the time of visit. An exit interview was conducted, and a copy of this report was reviewed and provided to Licensee, Emelita M. Price.the state’s words, verbatim · CDSS document, Mar 22, 2022

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: Case Management - Other

On 3/22/22 Licensing Program Analyst (LPA)’s David Cuevas and Chinwe Nwogene visited facility to do an annual inspection, while doing walk through of facility with Licensee, Emelita M. Price LPA ‘s identified passageway in garage leading to an emergency exit to be obstructed by a door placed sideways. Per Licensee, this is intended to keep pet dog from running away. Deficiency will be cited and civil penalties assessed. Additionally, during walk through LPA’s identified a bedroom to have been built within the garage, per Licensee bedroom was built about 7 months ago. LPA’s identified a staff to be residing in that bedroom. Staff is live scanned and associated to the facility. LPA’s advice Licensee that a follow up case management visit will be needed to ensure that bedroom in garage was included in the original submitted floor plan. Based on observations deficiency will be cited on LIC 809 D. An exit interview was done with Licensee, Emelita M. Price in which this report, LIC 809D, Civil Penalties, and appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 22, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Mar 22, 2022

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.This requirement was not met evidence by. While touring facility LPA identified an obstructed passageway leading into an emergency exit doorway within the garage. Per facility staff this is done to prevent pet dog from going to other areas of the home. This possess an immediate risk to the health, safety, and personal rights of residents in care.the state’s words, verbatim · CDSS document, Mar 22, 2022

Plan of correction: Licensee removed the door placed sideways from passageway during the visit. Additonally, a statement of understanding will be submtted as it relates to regulation being cited.