New Vision Services Senior Care 3

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Required 1 Year Inspection Visit utilizing the infection control domain. LPA met administrator and explained the purpose of the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; facility administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by administrator. LPA and administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, and common restrooms. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and facility staff completed the infection control domain and facility was found to be in substantial compliance at this time. LPA observed hot water temperature was measured at 117.3 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire Extinguishers were inspected on 12/8/2022 and in compliance. Smoke and carbon monoxide detectors are in compliance with fire safety. LPA observed centrally stored medications locked up in medication rooms. LPA reviewed three (3) client and three (3) staff files, including criminal record clearances. LPA reviewed Fingerprint clearance and associations to the facility. First aid kit was checked and is complete. LPA received the following updated documents on today's date: LIC 610-E - Emergency Disaster Plan, Administrator Certificate, and Liability Insurance. No deficiencies are being cited as a result of today's inspection. Exit interview conducted and copy of report left with administrator.the state’s words, verbatim · CDSS document, Mar 11, 2023

Allegation investigated: Family was not notified of residents’ pressure ulcer - SUBSTANTIATED Facility is not following doctors ordered diet - SUBSTANTIATED

/11/2022 10:30 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with house manager Lindsey Domreis. The purpose of this visit was to deliver the results of the complaint investigation of the above allegations. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 Mask, gloves. In addition, LPA was screened by facility staff. During the course of the investigation house manager and 4 staff were interviewed. LPA obtained the following documents to investigate the above allegations: LIC602 Physician's Report, Admission Agreement, LIC603A Resident Appraisal form, List of medications, Staff Roster, Notice of Inability to Continue Care, Text messages, photographs of pressure ulcer and example meal, home health nursing notes. Continued on LIC9099-C Substantiated Family was not notified of residents’ pressure ulcer – SUBSTANTIATED LPA review of documents revealed that starting on 02/09/2022 R1 was being treated in the facility by home health for a stage 2 pressure injury. Various text messages received between 02/05/2022 – 02/07/2022 confirmed that the family was aware that R1 had an on-going spot that was visible during R1’s admission to the facility. On 02/05/2022 the family was notified that the spot opened up and the facility had been treating it for 1 week. At this time family stated they thought the facility would inform them if they were treating R1 for a pressure injury. During staff interviews it was learned that when R1 moved into the facility they already had the pressure injury and the family was aware of it. House manager stated R1’s family member was present in the bathroom when the facility did R1's physical assessment. When R1 moved in R1 had a wound on their hip that had a band aid on it. The family supplied a cream to put on the wound. The wound healed and came back a few times. The family took R1 back to see their doctor in February 2022 and home health was ordered for R1. Administrator texted the family and notified the wound was getting bad again and was not healing. The family said, “I wish you would have told me sooner.” It was determined that although the family was aware that R1 had an ongoing issue with the pressure wound, the family was not notified in a timely manner that the wound had opened up until 1 week after discovery by the facility therefore the allegation is substantiated. Continued on LIC9099-C Facility is not following doctors ordered diet – SUBSTANTIATED LPA review LIC602 Physicians Report dated 12/31/2021 revealed that R1 required a special diet with thickened fluid, pureed diet. Text from family states that LIC602 issued by R1’s physician had “NO” checked in the column for special diet. Daughter took the LIC602 back to the doctor the same day for correction, daughter planned to pick up the LIC602 on 01/05/2022. LPA review of home health nursing notes for R1 revealed that the RN had reviewed a signed order in the facility from R1’s physician that required a pureed diet and thickened fluids. RN confirmed this requirement during telephone call with R1’s physician. RN stated that facility staff informed RN that R1’s DPOA had OK’d for soft foods. RN was not provided any documentation to confirm this. Interview with RN revealed that RN witnessed facility staff feeding R1 cottage cheese and halved strawberries with thin fluids. RN asked why they were not following R1’s diet that was ordered by MD. Facility staff said that R1's family ok'd for R1 to have a soft diet. RN asked the facility staff if R1 had anything in writing saying so, staff said "NO." RN states they followed-up with R1’s family and family deny giving the facility permission in following a different diet than what has been ordered. Three of four staff interviewed stated that they were aware that R1 required a pureed diet. One staff stated that R1 required a soft mechanical diet. Two staff stated that they provided R1 with a pureed diet. One staff stated they work nights and don’t provide food. One staff stated that they provided R1 with soft foods. Continued on LIC9099-C House manager stated that the physician had initially filled out NO to special diet on the LIC602 Physician's Report. A family member then took the Physician’s Report back to R1’s doctor and the doctor changed the form rather than filling out a new form. The date that the doctor made this change is unknown. LPA reviewed a black and white photograph with three bowls, one containing cubed vegetables, the second contains beans, and the third contains an unknown substance. There are handwritten notes in the margins that state “When giving R1 meals they need resemble this picture. She always needs a main, a side, and a veg. R1 can eat soft foods whole like the beans and mixed veggies. Per family members.” The photograph is dated 01/05/2022. House manager stated that she and a family member made the meal together as an example of what R1 should eat and the house manager took a photograph and made the notes. It was determined that even though the family indicated that it was OK for R1 to have a soft diet the facility always has to follow the LIC602 Physicians Report that prescribes the required diet for the resident. LPA requested the LIC602 Physician’s report from the facility three times and all copies that were provided to LPA by the facility indicate that R1 requires a pureed diet. RN witnessed staff giving R1 soft food which is not the prescribed diet for R1. The allegation is substantiated. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview was conducted and the report was emailed to house manager Lindsey Domereis, and administrator Melissa Johnson.the state’s words, verbatim · CDSS document, Aug 11, 2022 · control 25-AS-20220321145705

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Aug 25, 2022

87466 Observation of the Resident - 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. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: Based on LPA interviews and records review it was determined that although the family was aware that R1 had an ongoing issue with the pressure wound, the family was not notified in a timely manner that the wound had opened up until 1 week after discovery by the facility which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 11, 2022

Plan of correction: Administrator agrees to review regulation and submit a statement of understanding. Additionally, Administrator to submit a plan of how facility staff will notify physician and responsible party of resident changes in a timely manner. The proof of correction is to be received by LPA Knight by 8/25/2022.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(7) · Plan of correction due date: Aug 25, 2022

87555 General Food Service Requirements - (b) (7) The following food service requirements shall apply: Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement is not met as evidenced by: Based on LPA interviews and records review it was determined that the facility was not adhering to the resident’s prescribed pureed diet as listed on the LIC602 Physicians Report on file at the facility which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 11, 2022

Plan of correction: Administrator agrees to conduct staff training on the requirement that staff follow Physician’s Orders when a resident has a prescribed diet. Administrator to send in-service curriculum and staff attendance sheet with signatures to LPA Knight as proof of correction. The proof of correction is to be received by LPA Knight by 8/25/2022.

Type of visit: Required - 1 Year

On 03/15/2022 Licensing Program Analyst (LPA) Misty Valencia, arrived at the facility unannounced on 07/28/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Administrator Melissa Johnson and explained the purpose of the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Facility Administrator Melissa Johnson and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by Melissa Johnson.. LPA and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, and common restrooms.. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and facility staff completed the infection control domain and facility was found to be in substantial compliance at this time. No deficiencies are being cited as a result of todays inspection. Exit interview conducted and copy of report emailed to administrator.the state’s words, verbatim · CDSS document, Mar 15, 2022