New West Haven II

Allegation investigated: Facility staff gave wrong medications to a resident

On 8/16/2023, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to conduct interviews and deliver complaint findings into the allegations listed above and met with Administrator Jennifer Scarberry. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: **Report continued on 9099-C** Substantiated Facility staff gave wrong medications to a resident. During the course of the investigation for the above allegation, the department conducted interviews and record reviews. Department investigated allegation “Facility staff gave wrong medications to a resident” and interviewed staff. During interviews with staff, and records reviewed; it was determined that, staff dispensed the wrong medication to a resident in care, to be substantiated. Department received an incident report on a LIC624 regarding the medication error involving R1. Through documentation reviewed, it was determined that staff distributed mediation to R1 in error. The facility documented the medication error and did seek medical observation and treatment for R1 following the error. Based on information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview with administrator. Appeals rights provided. Copy of the report provided to facility.the state’s words, verbatim · CDSS document, Aug 16, 2023 · control 59-AS-20230405155446

From the deficiency page — Deficiency type: Type A · Section cited: CCR 80075(b)(5)(B) · Plan of correction due date: Aug 17, 2023

80075 Health Related Services (b)(5)(B) - Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by: Based on record reviewed and interviews, R1 was given the wrong medications in error. These medications were not ordered by R1s physician, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 16, 2023

Plan of correction: Licensee/Administrator agreed to submit a self-certification in regard to providing medication training for all staff regarding medication administration and submit proof to LPA by POC date- 8/17/2023.

Type of visit: Case Management - Legal/Non-compliance

On March 21, 2023, Licensing Program Analyst (LPA) Lavinia Muscan and Licensing Program Manager (LPM) Laura Munoz conducted a case management inspection to follow up on a substantiated allegation resident because severely dehydrated resulting in hospitalization due to lack of care and supervision. LPA and LPM spoke to Licensee, Joel Matkovich on the phone and met with Administrator, Jennifer Scarberry and explained the purpose of the visit. On May 13, 2019, the Department concluded a complaint investigation for allegations that a resident (R1) became severely dehydrated resulting in hospitalization. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. Throughout the course of the investigation, the Department conducted interviews with former staff, current staff, and R1’s family member who will be referred to as W1; reviewed EMS reports, hospital records, and facility records, including but not limited to: RTask notes, service recaps, incident reports, and R1’s facility file. Continuation on 809C... The Department reviewed the facility’s ongoing notes, RTask Campus Memo History, from February 10, 2018, to September 25, 2018. Notes on September 5, 2018, at 6:58 p.m., indicated a staff member entered a note stating R1 complained of lower back and stomach pain but refused medication. Memo further stated, “So please keep an eye on R1, maybe we could call R1’s son an[d] see if he can get R1 a dr. appt about their back.” No other notes are available for R1 after September 5, 2018. Staff (S2) stated that R1 wasn’t eating as much as the week prior due to back pain, and that for about two (2) days, R1 wasn’t getting out of bed. Staff (S3) stated R1 “didn’t look good” the last two (2) days at the facility, and that R1 had stayed in bed those days. S3 further stated that R1 refused one meal per day for about a week leading up to R1 going to the emergency room. Medical documents reviewed show that R1 was admitted to the emergency room on September 25, 2018, after facility staff contacted 9-1-1 because R1 was found in their room in an altered state of consciousness. Hospital records reviewed stated R1 was diagnosed with: hypernatremia (high sodium in the blood that is often caused by dehydration), acute kidney injury on chronic kidney disease stage III, methicillin-resistant staphylococcus aureus positive, leukocytosis reactive, and atrial fibrillation with rapid ventricular response. Medical reports indicated the acute kidney injury was from dehydration. EMS report from September 25, 2018, stated that, “care facility staff states pt has been bed confined for 2 weeks and also has had slurred speech times 2 days.” R1’s planned services provided by the facility stated that R1 was to have hydration recorded and for staff to push fluids. Service Recap from dates September 2, 2018, to September 25, 2018, provided by the facility show that the last time R1’s hydration was recorded was on September 17, 2018, and the last time push fluids was recorded was September 18, 2018. RTasks notes from dates September 9, 2018, to September 25, 2018, provided by the facility show the last recorded amount of “hydration” at 8:53 p.m. on September 18, 2018, in the amount of “4 oz of fluid.” There were no records on hydration for R1 after September 18. 2018. Current and former staff members told the Department that R1 needed reminders to drink water, and that hydration was supposed to be recorded for how many fluids R1 was getting. In interviews with Staff (S1), S1 stated R1’s condition “went way too far,” and R1 should have gotten more medical attention sooner than R1 did. S1 further stated that it was difficult to know how much liquid R1 was given because R1’s liquid intake was not properly documented. Continuation on 809C ... The above allegations were substantiated, and deficiencies were cited for violating the following California Code of Regulations (CCR) Title 22: 87464 Basic Services (f)(1) Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). (c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care. 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. The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. Per Welfare and Institutions Code § 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of or protracted loss or impairment of function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including, but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by facility staff did not follow R1’s needs and service plan by providing R1 adequate liquids which resulted in R1 becoming dehydrated. The facility did not seek timely medication attention when (R1) became severely dehydrated resulting in hospitalization for acute kidney injury. Today, March 21, 2023, the Department will be issuing a civil penalty per Health and Safety Code §1569.49(f) in the amount of $10,000 for a violation the Department constitutes as a serious bodily injury. A copy of the LIC 421D was given to the facility representative. Exit interview conducted. Appeal Rights provided. A copy of the report issued. Signature on these reports acknowledges receipt of these rights, found on page 2 of LIC 421D.the state’s words, verbatim · CDSS document, Mar 21, 2023

Type of visit: Case Management - Legal/Non-compliance

On March 21, 2023, Licensing Program Analyst (LPA) Lavinia Muscan and Licensing Program Manager (LPM) Laura Munoz conducted a case management inspection to follow up on a substantiated allegation of failure to seek medical attention in a timely manner. LPA and LPM spoke to Licensee, Joel Matkovich on the phone and met with Administrator, Jennifer Scarberry and explained the purpose of the visit. On August 5, 2021, the Department concluded an investigation for allegations that staff did not seek medical attention in a timely manner and staff did not notify authorized representative in charge of health conditions. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. Based on interviews with facility staff, medical staff and R1’s responsible party and facility and hospital medical records reviewed, the Department determined that R1 had a fall on April 27, 2021 and had experienced pain after the incident. The facility did not seek immediate medical attention after the fall or when the R1 first complained of subsequent pain. On May 3, 2021, R1's leg was warm to the touch, purple, and swollen. The facility did not inform R1's Power of Attorney about the fall and pain until R1 was finally sent to the hospital on May 3, 2021. At the time of admission, R1 was diagnosed with acute deep vein thrombosis (DVT) of popliteal vein of left lower extremity and closed displaced intertrochanteric fracture of left femur. R1 was discharged back to the facility on Hospice and passed away on May 24, 2021. R1’s death report listed cause of death as Congestive Heart Failure, and Aortic Stenosis. Other significant conditions are listed as: Atrial Fibrillation and Dementia. Continued on the 809C ... The above allegations were substantiated, and deficiencies were cited for violating the following California Code of Regulations (CCR) Title 22: § 87465(g) 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 § 87469(c)(2), (c)(3), or (c)(4). § 87468.1(a)(8) Personal Rights of Residents in All Facilities - (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. At the time of the visit, no immediate civil penalty was issued to the facility. On September 16, 2021, the Department conducted a non-compliance conference with the Licensee. At the time of the office meeting, the issuance of an immediate civil penalty for $500 was issued regarding the incident described above and the Licensee was informed that an additional civil penalty may be assessed at a future date per Health and Safety Code § 1569.49(f). The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. Per Welfare and Institutions Code § 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of or protracted loss or impairment of function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including, but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the facility’s failure to obtain timely medical care for the resident between approximately April 27, 2021 and May 3, 2021 after a fall resulting in the resident suffering a fracture of the left femur and acute deep vein thrombosis. Continued on the 809-C Today, March, 21, 2023, the Department will be issuing a civil penalty per Health and Safety Code §1569.49(f) in the amount of $10,000 for a violation the Department constitutes as a serious bodily injury. However, since an immediate civil penalty of $500 was previously issued on September 15, 2022, the amount of the civil penalty issued today will be $9500. A copy of the LIC 421D was given to the facility representative. Exit interview conducted. Appeal Rights provided. A copy of the report issued. Signature on these reports acknowledges receipt of these rights, found on page 2 of LIC 421D.the state’s words, verbatim · CDSS document, Mar 21, 2023

Type of visit: Required - 1 Year

On 02/14/2023 Licensing Program Analyst (LPA) Lavinia Muscan, arrived at the facility unannounced to conduct an annual visit using the infection control tool visit. LPA met with Facility Administrator, Jennifer Scarberry 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. LPA ensured she used hand sanitizer shortly after entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. 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, outside area and common restrooms. Facility has a 2 day perishable and a 7 day non-perishable amount of food. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Administrator completed the infection control domain and facility was found to be in substantial compliance at this time. Facility has 33 residents 2 of which are on hospice. Administrator agrees to send in LIC500 and liability insurance. No deficiencies are being cited as a result of todays inspection. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Feb 14, 2023

Allegation investigated: Resident wasn’t provided medications as prescribed Face mask are not being worn

LPA Parks arrived on September 9, 2022 to conclude a complaint investigation regarding the above allegations. Prior to the visit, LPA completed the 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 she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. Throughout the course of the investigation, LPA interviewed staff and residents. LPA reviewed documents pertaining to R1 including medication administration record (MAR), medication list, and activity of daily living reports (ADL). Based on observation, upon entering the facility, no staff were wearing masks. Additionally, based on interview of staff and residents, staff do not consistently wear masks when interacting with residents. Therefore, the allegation that face masks are not being worn is SUBSTANTIATED. Substantiated Based on interviews and review of documentation, medications are often not routinely given or given correctly. Based on the review of R1’s MAR, the following dates do not show the prescribed medication Lorazepam as being given (Note all dates are from 2021) : August 2 at 8am and 4pm, August 4 at 12am, 4 am, 8am, and 12 pm, August 5th at 4pm and 8pm, August 6 at 8am and 12 pm, and August 7th at 8am and 12 pm. Therefore, the allegation that resident was not provided medications as prescribed is SUBSTANTIATED. As a result of this investigation, the Department finds the allegations to be Substantiated. A finding that the complaint is Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiency is cited on 9099-D, per Title 22 Regulations, Division 6. Exit interview conducted. Appeal rights were given. A copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Sep 9, 2022 · control 25-AS-20210816201752

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87645(a)(5) · Plan of correction due date: Sep 12, 2022

87465(a)(5) Incidental Medical and Dental Care-The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: based on interview and MAR document review, residnet was not given medication as prescribed.the state’s words, verbatim · CDSS document, Sep 9, 2022

Plan of correction: Administrator to submit training plan and schedule for med techs by end of day Monday.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80072(a)(2) · Plan of correction due date: Sep 23, 2022

Personal Rights. (a) Each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement was not met as evidenced by: Based on observation and interview, masks were not consistently being worn by staff.the state’s words, verbatim · CDSS document, Sep 9, 2022

Plan of correction: Administrator to submit proof of training for all staff regarding facility's mask policy

Allegation investigated: Staff not providing adequate service to resident(s) in care.

LPA Parks arrived on September 9, 2022 to conclude a complaint investigation regarding the above allegations. Prior to the visit, LPA completed the 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 she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. Throughout the course of the investigation, LPA interviewed staff, residents, and performed a document review. LPA was not able to determine that services were not provdied to residents in care. Based on information obtained during the investigation, LPA finds the allegation 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. Exit interview. Copy of report provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 9, 2022 · control 25-AS-20210816201752

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.

Allegation investigated: Staff failed to respond to resident's call assistance button in a timely manner Staff left resident in soiled diaper for extended period of time Facility is malodorous

On 8/18/2022, Licensing Program Analyst (LPA) Jacob Williams arrived at the facility and met with Lacey Ripoll, Med Tech, to conclude a complaint investigation into the allegations listed above. LPA wore surgical mask and self-screened prior to entering. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: ** Report continued on 9099-C ** Unsubstantiated Allegation: Staff failed to respond to resident's call assistance button in a timely manner Based on document review and interviews of R2-R10, two residents complained of experiencing wait times of 1 hour once alerting their pendant. Allegation: Staff left resident in soiled diaper for extended period of time Interviews conducted with Residents (R2-R10) indicate that facility staff assist residents with continence care within in a reasonable amount of time. Allegation: Facility is malodorous During visit conducted on 8/18/2022 the Department found the facility to be clean and in good repair. LPA entered the room in question and did not notice an unpleasant odor. Through interviews of R2-R10, no residents complained of malodor. Based on interviews conducted by the Department and observation, the preponderance of evidence standards has not been met. Therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that a complaint allegation 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. Exit interview was conducted with Administrator and a copy of this report was provided to the facility. The signature of the Administrator on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Aug 18, 2022 · control 25-AS-20220427095808

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Sep 2, 2022

Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs… Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. This requirement is not met based on records and statements that found residents have lapses in care and missed medications due to insufficient staff. This posed an immediate risk to residents health and safety.the state’s words, verbatim · CDSS document, Aug 18, 2022

Plan of correction: Licensee shall submit an action plan explaining what steps the facility will take to maintain sufficient staff to meet residents needs. Please submit to:CCLD no later than POC date of 9/2/2022.

Allegation investigated: Resident sustained unexplained injuries while in care Facility is unkept

On 8/18/2022, Licensing Program Analyst (LPA) Jacob Williams arrived at the facility and met with Med Tech Lacey Ripoll to conclude a complaint investigation into the allegations listed above. LPAs wore surgical mask and self-screened prior to entering. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: ** Report continued on 9099-C ** Unsubstantiated Allegation: Resident sustained unexplained injuries while in care Interviews conducted with Residents (R2-R7) indicate that facility staff treat them with quality care, and have never witnessed any staff being rough with them or any fellow residents. Reviewing R1's medication log, they were prescribed meds that are known blood thinners which can cause bruises. Allegation: Facility is unkept During visit conducted on 5/27/2022, the Department found the facility to be clean and in good repair. The Department did not witness unkept areas at the facility. Based on interviews conducted by the Department and observation, the preponderance of evidence standards has not been met. Therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that a complaint allegation 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. Exit interview was conducted with Administrator and a copy of this report was provided to the facility. The signature of the Administrator on these forms acknowledges receipt of these documents. Allegation: Staff mismanaged resident's medication The department reviewed pertinent documents and conducted interviews with residents (R2-R10). It was found that in R1's MAR, there is no documentation of 10 separate types of medications given to R1 for 26 days in April 2022. Per staff interview, all medication should either be given to resident or otherwise an explanation should be included why it was not able to be given, which was not done. Also through interviews, four residents noted significant issues with not receiving their appropriate medication. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the allegation 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 provided.the state’s words, verbatim · CDSS document, Aug 18, 2022 · control 25-AS-20220517165901

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(5) · Plan of correction due date: Sep 2, 2022

87465(a)(5) Incidental Medical and Dental Care-The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on LPAs record review and interview, staff failed to provide medication to resident in a timely manner as prescribed. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 18, 2022

Plan of correction: Licensee agrees to conduct an in-service medication training with all staff no later than 9/2/2022. Licensee will submit a copy of training and roster with signatures to LPA by 9/2/2022. The proof of correction is to be received by LPA Williams by 9/2/2022.

Type of visit: Required - 1 Year

Unannounced annual visit utilizing the infection control domain was performed by LPA Michael Smith. Contact with Tania Langland. A review of staff records on 4/7/22 indicates that all facility staff and other individuals who require caregiver background checks have received criminal record clearances. As a result of this visit, there were no deficiencies. However, 2 technical advisories were issued. Exit interview conducted.the state’s words, verbatim · CDSS document, Apr 7, 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: Required - 1 Year

Unannounced annual visit utilizing the infection control domain was performed by LPA Michael Smith. Contact with Tanya Langland.. A review of staff records on 12/23/21 indicates that all facility staff and other individuals who require caregiver background checks have received criminal record clearances. As a result of this visit, there were no deficiencies. However, 2 technical advisories were issued. Exit interview conducted.the state’s words, verbatim · CDSS document, Dec 23, 2021

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: Office

Non compliance conference held via Microsoft teams meeting. Non-Compliance conference is documented on attached LIC 9111 As a result of the substantiated findings on IB Report # ND2521-05105 there will be additional deficiencies issued. See 809-D.the state’s words, verbatim · CDSS document, Sep 16, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(a) · Plan of correction due date: Sep 16, 2021

87355- Criminal Record Clearance- The Department shall conduct a criminal record review of all individuals specified in Health and Safety Code section 1569.17 and shall have the authority to approve or deny a facility license, or employment, residence or presence in the facility, based upon the results of such review. This requirement is not met as evidenced by: Based on the investigation, staff members, 1) Ashley Kelly 2) Olga Estrada 3) Kitty Flannagan and 4) Joshua Sullivan were present and working in the facility without being criminally cleared. Licensee did not have the above referenced individuals criminally cleared prior to being present in the facility. This is in violation of this section. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 16, 2021

Plan of correction: All staff shall be criminally cleared prior to working in the facility. Civil penalties shall be issued for this deficiency. ***Deficiency cleared***

From the deficiency page — Deficiency type: Type A · Section cited: CCR87207 · Plan of correction due date: Sep 16, 2021

87207-False Claims-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 is not met as evidenced by: Based on investigation, staff member Sunnybrook Matkovich, submitted a back dated UIR and lied to the department's investigator about the actual date of submission. This is in violation of this section. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 16, 2021

Plan of correction: Facility shall train all staff in the topic of false claims and shall not make false statements or mislead CDSS is such statements. This shall be done within 15 days. Facility shall send training documentation to LPA to clear this deficiency.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(A)(1)(b) · Plan of correction due date: Sep 16, 2021

87211-Reporting Requirements-A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence. (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement is not met as evidenced by: Based on the investigation, facility failed to report an incident where R1 sustained a fractured hip. Licensee is in violation of this section. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 16, 2021

Plan of correction: Facility shall train all staff in reporting requirements. This shall be done within 15 days. Facility shall send training documentation to LPA to clear this deficiency.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(a) · Plan of correction due date: Sep 16, 2021

Administrator - Qualifications and Duties - The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This requirement is not met as evidenced by: Based on witness statements and investigation, administrator Joel Matkovich, is not physically present in the facility to adequately manage the facility and is in violation of this section. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 16, 2021

Plan of correction: Facility shall submit an administrator's schedule in which the administrator shall be physically present in the facility. Facility shall submit a designated substitute administrator in the administrator's absence. Documentation shall be sent to LPA to clear this deficiency. This shall be done within 15 days.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87761 · Plan of correction due date: Sep 16, 2021

87761- Penalties- This requirement is not met as evidenced by: Based on the investigation, R1s injuries and the failure to report the injuries mandates the requirement of an enhanced civil penalties. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 16, 2021

Plan of correction: Civil Penalties for violations resulting in injury/death/ serious violation are pending a departmental review at this time. At the time of this report, no Civil Penalties are being assessed. Once a civil penalty assessment has been determined, LPA will return at a later date to assess the civil penalty.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87755(c) · Plan of correction due date: Sep 16, 2021

87755-Inspection Authority of the Licensing Agency-The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Records may be removed if necessary for copying. This requirement is not met as evidenced by: Based on the investigation and witness statements ,facility failed to furnish requested records by a duly authorized representative of the department. Licensee did not furnish requested records and is in violation of this section. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 16, 2021

Plan of correction: Facility shall submit a written statement that it will comply with any and all requests from CCL to provide or review facility documentation. This shall be done within 15 days. Facility shall send this statement to LPA to clear this deficiency.

Allegation investigated: Staff did not seek medical attention in a timely manner. Staff did not notify authorized representative in change of health conditions.

LPA Lusby arrived on Thursday August 5, 2021 to conclude a complaint investigation regarding the above allegations. Prior to 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 she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. Throughout the course of the investigation, the Department interviewed R1's Power of Attorney and family, assigned hospital physician, care staff, clients in care, and facility Administrator. Additionally, the Department reviewed staffing schedules, employee roster, R1's service plan, physicians report, resident notes, admission agreement, resident profile, and incident reports. The Department learned that R1 had a fall on 4/27/2021 and (continued on 9099-C) Substantiated was in pain after. The facility did not seek treatment for the fall and subsequent pain. On 5/3/2021, interviews revealed that R1's leg was warm to the touch, purple, and swollen. The facility did not inform R1's POA about the fall and pain until she was sent to the hospital on 5/3/2021. As a result of this investigation, the Department finds the allegations to be Substantiated. A finding that the complaint is Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiency is cited on 9099-D, per Title 22 Regulations, Division 6. Exit interview conducted. Appeal rights and a copy of this report was given to Sunny Matkovich. resulted in a fracture, it was not able to be determined that this was due to neglect or lack of supervision from staff. Due to this information the preponderance of evidence standard has not been met, therefore the above allegation is determined to be UNSUBSTANTIATED. Exit interview conducted. A copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Aug 5, 2021 · control 25-AS-20210507131959

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Aug 6, 2021

87465Incidental Medical & 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 . . . This requirement was not met as evidenced by R1 sustaining a fall and the facility failing to seek medical attention.the state’s words, verbatim · CDSS document, Aug 5, 2021

Plan of correction: Licensee to submit scheduled date of training for all staff regarding when to call 911 and emergency procedures.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: Aug 20, 2021

87468.1 Personal Rights of Residents in All Facilities (8) To have their representatives regularly informed by the licensee of activities related to care or services . . . This requirement was not met as evidenced by R1 sustaining a fall which was not reported to R1's POA until R1 was sent out via 911 days later.the state’s words, verbatim · CDSS document, Aug 5, 2021

Plan of correction: Licensee to submit scheduled date of training for all staff regarding who to call after a resident's fall or change of condition.

Allegation investigated: Resident's suffered multiple falls while in care. Medications are not labeled. Staff not administering medications in a timely manner. Resident's developed a pressure injury while in care. Staff not administering medications to resident's. Staff denied resident food. Inadequate staffing to meet the needs of the resident's. Staff did not ensure resident's are eating.

Prior to entering the facility, LPA Smith spoke with staff to pre-screen that the facility is COVID free. Analyst also self-screened for having no known symptoms or exposure. Analyst followed facility's screening protocols, wore an N-95 respirator and maintained distance during the visit. LPA Smith conducted an unannounced complaint visit and met with Ashley Kelley. LPA attempted to contact witnesses on multiple occasions and was unsuccessful. The complaint is completely devoid of any identifying information, resident names, staff names, dates of occurrences and witness names. Due to the generalized nature of the allegations it is impossible to narrow the focus of the investigation. Based on this, these allegations are UNSUBSTANTIATED. Unsubstantiated As a result of this investigation, LPA finds the allegation that resident's suffered multiple falls while in care, medications are not labeled, staff not administering medications in a timely manner, resident's developed a pressure injury while in care, staff not administering medications to residents, staff denied resident food, Inadequate staffing to meet the needs of the resident's and staff did not ensure resident's are eating 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 the evidence to prove that the alleged violations occurred.the state’s words, verbatim · CDSS document, Jul 8, 2021 · control 27-AS-20210104114931