Mary Frances Hat Residential Facility

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Renee Campbell arrived unannounced to conduct a case management visit on 10/03/23. LPA Campbell obtained information that the resident had resided in the home with a stage 3 pressure wound without an exception request. The Department conducted interviews, reviewed documentation submitted and determined that the resident had a Stage Three Pressure Wound after leaving the hospital on 06/16/2023. Based on interviews with administrator Laura Reeves, the resident was admitted back to the facility despite having no approved exception request from the Department. Licensing was not notified of the prohibited health condition and no exception request was received by licensing. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates, civil penalties may be assessed. The Facility Designee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, a copy of the report was given.the state’s words, verbatim · CDSS document, Oct 3, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Oct 13, 2023

Prohibited Health Conditions -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: Stage 3 and 4 pressure injuries. This requirement is not met as evidence by: Based on LPA Campbell’s observation of file reviews for R1 and Adventist Home Health Nurse’s statement that R1 had a Stage Three Pressure Wound while in the facility for more than 24 hrs. This poses an immediate risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Oct 3, 2023

Plan of correction: POC The licensee shall train all staff on prohibited health conditions and submit a signed attendance roster of all employees that were educated on the regulation along with a statement of understanding to LPA by POC due date of 10/13/2023.

Allegation investigated: Resident developed a pressure injury while in care due to lack of staff supervision.

On 09/20/2023, Licensing Program Analyst Renee Campbell arrived at Mary Francis Hat Residential Facility unannounced to conclude investigation 27-AS-20230627104114. LPA met with Laura Reeves and explained the purpose of the visit. In regards to the allegation, "Resident developed a pressure injury while in care due to lack of staff supervision", the Department confirmed R1's pressure wound was a result of a hospital stay and was not sustained at Mary Francis. The pressure wound was first noticed when R1 returned from a hospital stay from 6/8/2023 through 6/12/2023. The wound was not severe and it was being treated properly with creams, repositioning, and pillows. After another hospital visit on 6/16/2023, R1’s wound ruptured and when a Wound Care Nurse (N1) saw the wound afterwards, it was unstageable. Mary Frances staff enlisted the help of N1 to treat R1 and teach Mary Frances staff how to care for the wound. Per S1 and N1, R1’s pressure wound was a result of the Emergency room visit on 6/16/2023. Unsubstantiated The investigation revealed the preponderance of evidence standards has not been met; therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. An exit interview was conducted with Administrator Laura Reeves and it was requested to sign todays report, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 20, 2023 · control 27-AS-20230627104114

Allegation investigated: Facility is retaining a resident with a higher level of care needs.

****THIS DOCUMENT WAS AMENDED TO CHANGE THE FINDING FROM UNFOUNDED TO UNSUBSTANTIATED AND TO CORRECT THE DATE.** On 09/07/23, Licensing Program Analyst Renee Campbell arrived at Mary Francis Hat Residential Facility unannounced to conclude investigation 27-AS-20230627104114. LPA met with Laura Reeves and explained the purpose of the visit. Regarding the allegation, “Facility is retaining a resident with a higher level of care needs”, LPA obtained information that the facility notified the responsible party that R1 was in decline and in need of hospice care on approximately 6/8/23. On 06/22/23, R1’s primary care doctor referred R1 for hospice care. LPA observed an email on 6/23/23, whereas the administrator, Laura Reeves informed the responsible party of the doctor’s referral and requested feedback. The administrator reached out to the Service Coordinator for an update on approval for hospice care for R1. The facility has a waiver for 2 hospice residents. At this time, there are 0 residents receiving hospice care services. The investigation revealed that the primary care physician and Senior Community Liason for the hospital, reached out to the responsible party, explained the need for hospice care, at which time, the responsible party declined hospice care. Unsubstantiated Based on facility having an approved waiver for two hospice residents, at which time there were zero, the allegation is deemed as unsubstantiated. This agency has investigated the complaint alleging "Facility is retaining a resident with a higher level of care needs". A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. We have therefore dismissed the complaint.” Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited. An exit interview was held and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 7, 2023 · control 27-AS-20230627104114

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Required 1 Year Annual Inspection Visit. LPA met with administrator and explained the purpose of today’s inspection. LPA was allowed entry into the facility after getting temperature checked and COVID-19 precautions. Facility is licensed to serve a total capacity of six non-ambulatory residents, currently there are four residents. LPA and administrator toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature for residents is maintained at 72 degree Fahrenheit. The hot water temperature was observed to be 109.7 degrees Fahrenheit, which is within the required regulation of 105 to 120 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. There is a minimum of 7 day non-perishables and 2 day perishables foods. LPA observed smoke detectors are interconnected with the fire department. Carbon monoxide is in operating condition. Fire extinguishers were last serviced on 2/7/2022. LPA observed mitigation plan completed. First aid kit observed to be complete. Fire drill was last conducted on 12/17/2022. LPA reviewed three (3) staff records and two (2) resident records. All files were complete. Staff are fingerprint cleared and first aid certified. Liability Insurance expires 3/1/2023. LPA observed medications and the MARS sheets. Medications appear to be documented appropriately. LPA received the following updated documents on January 9, 2023: Administrator Certificate, Articles of Incorporation, Liability Insurance, LIC 308 - Designation of Administrative Responsibility, and LIC 610-E Emergency Disaster Plan. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview conducted with administrator and a copy of report given.the state’s words, verbatim · CDSS document, Jan 9, 2023

Type of visit: Annual/Random

On 01/05/2022 at 9:00am, LPA T. White arrived unannounced to conduct a required 1-year Annual inspection. LPA met with Executive Assistant Kathy Moore and Director, Laura Reeves. LPA explained the purpose of today’s inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 6 non-ambulatory residents. LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature for clients is maintained at 72 degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. There is a minimum of 7-day nonperishables and 2-day perishables foods. LPA observed smoke detectors is interconnected with the fire department. Carbon monoxide is in operating condition. Fire extinguisher was last serviced on 02/18/2021. LPA observed mitigation plan completed. First aid kit observed to be complete. Fire drill was last conducted on 12/02/2021. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview conducted with Director and a copy of report given.the state’s words, verbatim · CDSS document, Jan 5, 2022

Type of visit: Required - 1 Year

On 10-26-21 at 2:01pm, Licensing Program Analyst (LPA) Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the administrator Laura Reeves and explained the purpose of the visit. LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside yard of the facility to ensure compliance with Title 22 regulations. Facility is a 6 bed residential care facility for the elderly with a current census of 4. Facility has 4 bedrooms and 2 bathrooms for resident use. There is a dining area of the kitchen. No obstructions to fire exits noted. LPA also conducted the infection control domain tool. The facility has an approved COVID Mitigation plan LIC 808 form in place.The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door, and back yard. The facility has a designated infection control lead. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use. Water temperature reads 107.2*F in the bathroom and room temperature reads 75*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was checked 2/18/2021. Facility has an emergency food and water kit. Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held with Laura Reeves and a copy of this report was given to Administrator Laura.the state’s words, verbatim · CDSS document, Oct 26, 2021

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.