Serenity Seniors Home III

Type of visit: Required - 1 Year

On 10/04/23, Licensing Program Analyst (LPA) Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Administrator DeAnthony Hardiman as the purpose of today’s visit was explained. The facility is licensed to serve 4 non-ambulatory of which 1 may be bedridden developmentally disabled clients (age 60 and over). Clients are linked with the South Central Los Angeles Regional Center. The facility is a single-story structure located in a residential neighborhood. It consists of the following: living room, kitchen, dining room, two (2) client bedrooms, one (1) furnished bedroom for isolation if needed, two (2) bathrooms of which (1) is private, a two-car detached garage that is used for storage and houses a washer and dryer, and a shaded patio area. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Toxins and knifes were observed to be locked and inaccessible to clients. Bathrooms were found to be within Title 22 regulations and were clean and operational. A comfortable temperature is maintained in the facility. LPA conducted a records review of 2 staff records, 2 client records, and 2 Medication Administration Records, No discrepancies observed. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire drill was conducted on 07/06/23, (2) fire extinguishers fully charged, carbon monoxide detectors and smoke detectors are operational. Landline and internet service was observed. Liability insurance is active. Exits/ Walkways around the facility were free of debris and hazards. During today’s visit no discrepancies were cited. Exit interview conducted with Administrator DeAnthony Hardiman, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 4, 2023

Type of visit: Required - 1 Year

On 11/10/22, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA was met by Antoinette Richardson, administrator, and the purpose of today’s visit was explained. The facility is licensed to serve residents age range 60 and over. The facilities annual fees are past due and have an outstanding balance of $742.00, which was due on 10/13/22. There are currently 4 South Central Los Angeles Regional Center clients in placement. The facility is a single-story structure located in a residential neighborhood. It consists of the following: living room, kitchen, dining room, two (2) resident bedrooms, two (2) bathrooms with a two-car detached garage and patio with chairs. As part of the inspection, my primary focus was on infection control. LPA observed the facility’s infection control practices: LPA observed a sanitizing station at the facility entrance. PPE supplies are readily available to staff and residents, and additional supplies are stored. Sufficient paper, cleaning, and disinfecting supplies were observed. The facility has the mandated COVID infection control posters. LPA and Ms. Richardson toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. 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. A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Continued on LIC 809-C Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is enough perishable and non-perishable food available. Both fire extinguishers were charged, smoke detectors and Carbon Monoxide were operable. Water temperature for the kitchen and bathrooms were complying. During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations (Located in common areas and restrooms). LPA observed staff and residents were wearing face coverings, an isolation room and required postings throughout the facility. LPA observed the facility has a 90-day supply of Personal Protective Equipment (PPE). LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing (www.cdss.ca.gov) Provider Informational Notices (PIN) for any updates relating to COVID-19 and other required guidance. During today’s visit there were deficiencies observed and no citations issued. Exit interview was held and a copy of the report were provided to Antoinette Richardson.the state’s words, verbatim · CDSS document, Nov 10, 2022

Allegation investigated: Severe neglect resulting in resident sustaining a stage 4 pressure injury.

Licensing Program Analyst (LPA) Vasallo conducted a subsequent complaint visit. The purpose of the visit was to correct LPA Arterberry's report dated 11/24/19. LPA Arterberry's report has been rescinded. The initial complaint visit was conducted by LPA Arterberry on 9/16/19. Investigator Santana investigated further. The investigation consisted of the following: On 9/16/2019, LPA Arterberry reviewed and obtained copies of Resident #1’s (R1’s) file which included the following: Health screening, Medication Administration Record (MAR), Admission Agreement, Ideal Health Care (Health Screening), MAR, Restricted Health Care Plan, Purity Home Health Care Services notes, Omni Home Health Care Services notes and Nurses Notes. Investigator Santana interviewed the following individuals: R1, Licensee, Maya Astier, Administrator, Candice Fulse, Staff #1 (S1), Regional Center Quality Assurance Specialist, Purity Home Health representative and Ideal Health Care representative. Continued on 9099C. Substantiated The investigation revealed the following: S1 indicated R1 had some redness in April 2019 after being hospitalized for an unrelated issue. Facility records also indicate R1 has a history of skin integrity issues. Licensee indicated R1 developed a pressure injury in May 2019 after being hospitalized. In August 2019, facility staff observed R1’s wound became larger. S1 admitted cleaning the wound prior to a medical professional treating it. On 8/12/19, Physician’s Assistant from Ideal Health visited the facility to conduct a routine wellness check on R1. Physician’s Assistant only observed the skin that was visible and did not check R1’s buttocks because staff did not report any issues with wounds at that time. On 8/13/19, facility staff notified the facility nurse consultant of R1’s wound. However, wound care was not ordered until 8/22/19, when R1’s physician submitted an order to Purity Home Health Services to provide wound care to R1’s sacrum and buttocks area. On 8/22/19, a home health nurse assessed R1’s wounds. The sacral pressure injury was determined to be a Stage IV. On 8/29/19, Purity Home Health Services provided the first wound treatment. The nurse noted the sacrum pressure injury and it’s dressing to be “very dirty with feces”. Facility staff were instructed to reposition R1 every 2 hours. Purity treated the wounds on 8/29/19 and 8/31/19. On 9/3/19, Omni Wound Physicians began treating R1’s wounds. The pressure injuries were now a Stage IV on the sacral area, a Stage III on the right buttocks and a Stage III on the left buttocks. Omni recommended R1 be evaluated at the hospital. Medical records from Southern California Hospital at Hollywood indicate R1 was admitted to the hospital on 9/5/19 because of a Stage IV pressure injury on the sacral area and acute metabolic encephalopathy. The chief complaint was being lethargic. R1 was admitted to the intensive care unit for septic shock among other conditions. R1 had multiple infections including a UTI and pneumonia. Facility staff argue home health nurses never left documentation describing the condition of the wound and never notified staff the wounds had worsened. Despite facility staff continuing to provide assistance with R1’s diaper changes. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview held. Administrator, Antoinette Richardson refused to find. A copy of the report and appeal rights were provided. The issuance of a civil penalty is being considered based on Health & Safety Code 1569.49(d); if the department determines the injury of the resident is due to severe neglect.the state’s words, verbatim · CDSS document, Apr 18, 2022 · control 28-AS-20190913095722

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Apr 19, 2022

Prohibited Health Conditions (a) 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: (1) Stage 3 and 4 pressure injuries. This deficiency was evidenced by the following: R1 was noted to have redness or a pressure injury around April or May 2019. Staff admitted the wound was worsening in August 2019. Treatment did not start until 8/22/19 when pressure injury was noted as a Stage IV.the state’s words, verbatim · CDSS document, Apr 18, 2022

Plan of correction: Licensee will certify regulations regarding prohibited health conditions will be followed. Staff will be trained on reporting prohibited health conditions to appropriate parties.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Apr 19, 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. This deficiency was evidenced by the following: Staff indicated they were unaware of the condition of the wound due to home health agencies not providing documentation. However, it’s the facility staff’s responsibility to obtain the required documentation to confirm their resident is provided adequate care.the state’s words, verbatim · CDSS document, Apr 18, 2022

Plan of correction: Licensee will certify that staff will communicate with home health agencies regarding residents' conditions.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ulysses Coronel conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA was met by Antoinette Richardson, administrator and the purpose of today’s visit was explained. The facility is licensed to serve residents age range 60 and over. 4 non-ambulatory of which 1 may be bedridden. There are currently 4 South Central Los Angeles Regional Center clients in placement. One out of four residents is non-ambulatory. The facility is a single story structure located in a residential neighborhood. It consists of the following: living room, kitchen, dining room, two (2) resident bedrooms, two (2) bathrooms with a two car detached garage and patio with chairs. LPA and administrator toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. 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. A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is enough perishable and non-perishable food available which is stored properly. Fire extinguisher was charged, smoke detectors and Carbon Monoxide were operable. During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations ( Located in common areas and restrooms). LPA observed staff and residents were wearing face coverings, an isolation room and required postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance. During today’s visit there were deficiencies observed, the water temperature measured between 124.1 and 126.0 F. Title 22, Division 6 Chapter 8 Article 08 is being cited, please see LIC9099D. Exit interview held and plans of correction developed. A copy of the report and appeal rights were provided to Antoinette Richardson.the state’s words, verbatim · CDSS document, Oct 14, 2021

The state marks this report as 9 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.