Regency Palms Long Beach

Allegation investigated: Resident sustained an injury due to an unwitnessed fall. Resident's call button is not accessible.

On 11/5/2021 at 8:25 a.m., Licensing Program Analyst (LPA)/ Susan Campos, initiated a 10-day complaint investigation visit for the allegations listed above. LPA was allowed entry into the facility by Administrator Carla Mariano. LPA explained to Ms. Mariano the purpose of the visit. The investigation consisted of the following: LPA conducted interviews with (5) staff members and (5) residents on 11/5/21. In addition, on 11/5/21, LPA and Ms. Mariano conducted an inspection, for health and safety of the facilities’ physical plant, and food supply, and also inspected all the facility resident room call button box stations. LPA also reviewed the following documents provided by Regency Palms Long Beach administrator Carla Mariano: LIC 500-staff roster, client roster, staff schedule, Incident Reports from October 2021 to present, List of Caregivers work hours on assigned floors, Internal staff incident reports from October 2021 to present, Staff NOC shift duties, October NOC shift facility room check reports, R1 case notes, R1 physician report, R1 service care and R1 medical documents. Report continued on LIC 9099C Substantiated Investigation Allegation: Staff is short staffed The investigation revealed, per LPA interviews, with (5) staff members, and (5) residents from the Regency Palms Long Beach facility and review of facility documents, that the Regency Palms Long Beach facility is not short staffed. The investigation revealed, per LPA interviews, with (5) staff members, and (5) residents from the Regency Palms Long Beach facility and review of facility documents, that the Regency Palms Long Beach is not short staffed. LPA interviewed S1, and the LPA was informed that the facility has two caregivers, assigned to each floor, for day and night shifts, (except 2, 6 and 7 floors that have 1 assigned caregiver), and one caregiver during NOC work shift assigned to each floor. Also, S1 stated that the Med-Tech on duty, with assigned caregivers, also supervises the caregivers, and makes sure that the residents are cared for. Furthermore, the caregivers sign off and endorse to the Med-Tech, once their work shift is completed, and verify that all their residents have been checked, and do not need assistance. S1 also stated that the management team do rounds in the facility, and check the residents, as does the Med-Tech, conduct rounds to verify that the resident’s needs are met, and other concerns do not need to be addressed. LPA interviewed 5 staff members, and 5 of 5 staff members informed the LPA, that staff members check on the residents, to ensure that there are no issues, and also 5 of 5 staff members informed the LPA that there is a staff endorsement process, at the end of a work shift, confirming that all residents have been checked, and that there are no issues with the residents. In addition, 5 of 5 staff members informed the LPA, that there is enough staff members to cover, the resident needs, on every work shift, and also that the Med-Tech and managers, support the caregivers if there is a need. The LPA interviewed 5 residents, and 4 of 5 residents informed, the LPA, that the caregivers assist them when needed, and also 4 of 5 residents informed the LPA, that the caregivers are available when needed. Based on information gathered, LPA did not find sufficient evidence to support allegation " Facility is short staffed ”. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted with Carla Mariano, Administrator, and a hard copy of a LIC 9099 was provided. Based on LPA observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. A telephonic exit interview was conducted with Carla Mariano, Administrator and a hard copy of a LIC 9099 and LIC 9099D was provided. Investigation Allegation: Resident sustained an injury due to an unwitnessed fall. The investigation revealed, per LPA interviews, with (5) staff members, and (5) residents from the Regency Palms Long Beach facility, and review of facility documents, that a Regency Palms Long Beach facility resident sustained an injury due to an unwitnessed fall . LPA interviewed S1, and the LPA was informed by S1, that R1 had sustained an injury on 10/27/21, at approximately 3:15 am, as a result, of a fall in R1’s room. R1 was immediately transported to the hospital, for medical follow up, and returned to the facility on the same day. S1 stated that R1 has bruises on the face and neck, and also a hematoma on the forehead. S1 informed LPA that R1 states that is not in pain or discomfort, and has returned to normal activities. S1 submitted to licensing incident report regarding the event prior to 7 day reporting deadline. On 11/5/21, at 9:30 am, LPA was informed by S1, that R1 fell in R1’s room, and sustained face and neck bruising and a hematoma on the forehead. Based on information gathered, LPA did find sufficient evidence to support allegation " Resident sustained an injury due to an unwitnessed fall ”. Allegation: Resident's call button is not accessible The investigation revealed, per LPA interviews, with (5) staff members, and (5) residents from the Regency Palms Long Beach facility, and review of facility documents, that R1’s call button is not accessible. In addition, S1 and LPA, inspected the facility resident’s room and bathroom call button boxes. S1 and LPA observed, 11 Call button boxes, with missing pull cords. In addition, the LPA pulled the cord on Room 401, and observed that a caregiver responded, to the call, in 5 minutes. On 11/5/21, between 10:20 a.m. – 11:40 a.m., LPA observed that 11 resident call box stations did not have an attached pull cord to activate the call box. Based on information gathered, LPA did find sufficient evidence to support the allegation " Resident's call button is not accessible ”. Report continued on LIC 9099Cthe state’s words, verbatim · CDSS document, Nov 5, 2021 · control 11-AS-20211101104748

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(i)(1)(A) · Plan of correction due date: Nov 5, 2021

87303(i)(1)(A)Maintenance and Operation (i) Facilities shall have signal systems which shall meet the following criteria:(1)All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall:(A)Operate from each resident's living unit. This requirement is not met as evidenced by: Based on interviews, and record review, the licensee failed to ensure the safety of resident, on 11/5/21, LPA and S1 observed that 11 facility resident room call box stations did not have a pull cord which posed a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Nov 5, 2021

Plan of correction: Administrator provided LPA with work order report dated 11/5/21, stating that the 11 identified facility resident room call box stations have each been installed with a pull cord on 11/5/21

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Nov 30, 2021

87468.1(a)(2)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:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. Based on interviews, and record review, on 11/5/21, S1 informed LPA that R1, fell in resident's room, and sustained injury which posed a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Nov 5, 2021

Plan of correction: Administrator will fax to LPA a copy of the Regency Palms Long Beach facility resident fall prevention plan, and also a copy of the fall prevention plan staff training sign in sheets. POC Due Date is 11/30/21 LPA Fax Number (323)981-1781

Type of visit: Required - 1 Year

On 10/7/21, at 9:37 am, Licensing Program Analysts (LPA) Susan Campos and Ngozi Nwaokoro conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA was allowed entry into the facility by Carla Mariano, Administrator. LPA met with Ms. Mariano and explained the purpose of the visit. The facility is licensed to operate for ninety-one ( 91) non-ambulatory with (10) may be bedridden, delayed egress on floors 2-8, hospice waiver for 15 residents. The facility is a white high rise 8 story building with a sprinkler system, located in a downtown commercial area. Included in the 8 floor structure is a basement, main floor, memory care community (floors 2,3,4,5) and assisted living community (floors 6,7,8) with a delayed egress at exit points present on floors 2nd – 5th. There are (2) fire extinguishers located on each floor. Water stations are located in the lobby and the dining room of each of the floors. The resident room unit has a smoke detector that are battery operated and one hard-wired and interconnected. Each facility floor has a dining room, staff room which includes a locked medication cart and first aid kit and is inaccessible to the residents and also on each floor is an all gender public restroom available for resident use. LPAs observed Main floor: Lobby, Reception area, and Executive Director office, Basement: Common Area/Activity Room, (3) Gender Neutral Public Restrooms, wall area with notifications and postings of resident rights, house rules and activities, medication room that was locked and inaccessible to the residents that included, magnetic locks on the cabinet, and a medication refrigerator, Laundry room with two commercial washing machines and dryers, supply cabinet with storage of towels, linens, fitted sheets, flat sheets, blankets, mattress pad, mattress covers, storage room contained personal care supplies, Beauty Salon, Activity Room/Art Studio with board games, reading materials and craft supplies, Business Office, Wellness Office, Fitness Room, Staff Lounge, Kitchen and PPE supply room and the Roof-9th floor patio area included string lights, 2 lattice patio covers, 3 umbrellas, and 3 sets of patio tables with chairs . In addition, LPAs inspected 14 resident rooms (#202A, #205, #301B, #304A, #306B, #402A, #405, #504B, #508, #604, #701A, #704, #801, #808 ). There were no bodies of water or obstructions on the premises. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client Evaluation Report Continues on LIC 809-C personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The hot water temperature was measured for 14 resident rooms and are noted as the following: (#202A-105 F, #205-107.7F, #301B-108.7F, #304A-108.5F, #306B-105F, #402A-105F, #405-110.1F, #504B-107F, #508-107.1F, #604-107.1F, #701A-109F, #704-106.7F, #801-107.1F, #808-109.2F ). A comfortable temperature of 73 degrees was maintained in the facility. The LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly. All facility (39) fire extinguishers were checked and are charged, (39) resident room smoke detectors were checked and are operable, and also the facility carbon monoxide detector was checked and is operable. Fire Drills were observed to be maintained in order and accurate. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, and LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff and resident temperature logs were reviewed. No deficiencies were cited during this inspection visit. An exit interview was conducted and a copy of this report was provided to Administrator Carla Mariano.the state’s words, verbatim · CDSS document, Oct 7, 2021