Sunset Coast Assisted Living

Allegation investigated: Staff neglect resulting in worsening pressure injuries Staff did not follow resident's care plan

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to deliver investigative findings. LPA was greeted by Caregiver, Leticia Castro Guizar to whom she identified herself. Administrator, Patricia Tapia joined the meeting via conference call and LPA shared findings. The Department investigated the above-listed complaint allegations. The investigation consisted of an inspection of the facility, observations, multiple interviews with residents, staff, and outside sources, and a detailed review of resident records, including medical records, chronological medical care, and service care plans. On December 14, 2021, Community Care Licensing (CCL) received a complaint alleging that facility staff neglect resulted in the worsening of pressure injuries for a resident (R1) in care. It was also alleged that facility staff did not follow the resident’s care plan for the same resident in care. [an LIC 811 Confidential Names List was provided to staff to identify the resident]. (continue at LIC 9099C) Unsubstantiated (Continue from LIC 9099) A detailed review of R1’s records indicated that R1 had a primary diagnosis of Alzheimer’s disease, as well as other serious illnesses, and was experiencing chronic pain when they were admitted to the facility on August 31, 2021. In addition, R1 was under medical care by an outside medical provider. On August 30, 2021, before R1 was discharged from the hospital and placed at the facility, a referral for routine home care was established by an outside provider to treat existing pressure injuries. In addition, the attending physician ordered and initiated antibiotics to treat the pressure injuries as well as a hospital bed with a low air loss mattress. A Licensed Vocational Nurse (LVN) reported that R1 had an ulcer on their coccyx when they arrived at the facility. A review of records of the care and supervision provided by staff as well as the outside medical provider indicated that R1’s service care plans were coordinated between facility staff and the outside medical provider. The records review and multiple interviews with staff and outside sources indicated that medical care was executed as prescribed to meet R1’s care needs. Medical records indicated that R1 had been receiving wound care since September 20, 2021. Facility documentation confirmed that staff were rotating R1 every two hours. The physician’s progress notes indicated that R1’s wound incidence was unavoidable due to R1’s advanced age and other pre-existing health conditions. The LVN continued to provide wound care three times per week. However, despite the routine and consistent medical attention provided, on December 13, 2021, at the request of facility staff, R1 was transported to the hospital to treat a possible wound infection. R1 was discharged back to the facility on December 18, 2021, with continued home care by an outside medical provider. R1’s medical team as well as responsible parties agreed to discharge R1 back to the facility with comfort care and antibiotics. Multiple interviews with staff and outside sources and a review of records confirmed that the staff adhered to R1’s service care plan and medical treatment recommendations. The Department has investigated the allegations and has found that there was insufficient evidence to corroborate the above allegations. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, these allegations are deemed to be unsubstantiated. An exit interview was conducted with Caregiver, Guizar and Administrator, Tapia, and a copy of this report, Confidential Name List (LIC 811), along with Licensee/Appeal Rights (LIC 9058 03/22) were provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Aug 14, 2023 · control 08-AS-20211214104556

Allegation investigated: Staff did not meet resident's dietary needs Staff did not meet resident's hygiene needs Staff did not provide quality food

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to deliver investigative findings. LPA was greeted by Caregiver, Katia Perez to whom she identified herself. Administrator, Patricia Tapia join the meeting via telephone and LPA shared findings. The Department investigated the above-listed complaint allegations. The investigation consisted of an inspection of the facility, observation of food storage areas, multiple interviews with staff and outside sources, and records review, including resident and facility records and photographs. On May 15, 2023, Community Care Licensing (CCL) received a complaint alleging that facility staff did not meet resident’s (R1) dietary needs [an LIC 811 Confidential Names List was provided to staff to identify the resident and staff (S1)]. It was specifically alleged that during a visit on April 26, 2023, a staff member (S1) was observed feeding R1 grilled “hotdog” meat with zucchini for dinner. (continue on LIC9099C) Substantiated (continue from LIC9099) It was indicated that R1 was having problems chewing and swallowing the meal because the ‘hotdog’ meat was causing R1 to choke. A review of outside source evidence submitted during the investigation and multiple interviews with staff confirmed the incident. A review of R1’s medical records disclosed that R1 was diagnosed with Alzheimer's dementia. In addition, a review of the care plan indicated that on December 9, 2022, R1’s physician ordered a change in diet to mechanical soft food because R1 had increased restlessness and difficulties swallowing. During an interview, S1 indicated that they had fed R1 “hotdog” meat successfully in the past and assumed it was safe. According to management, staff were allowed to purchase and store their own food at the facility, as long as it was kept separately. In addition, management indicated that “hotdog” meat was not part of the regular menu and should not have been served to the residents. A review of the menu for April and May 2023, did not disclose “hotdog” meat as a meal option. After the incident with R1, management provided additional training in food service and reminded staff to adhere to the menu meal options. As part of the training, the residents’ care plans were also reviewed with all staff to ensure residents’ dietary needs were met. It was also alleged that R1’s hygiene needs were not met. It was specifically alleged that on or about April 4, 2023, R1 was observed with feces under their fingernails. According to outside sources, this concern had been addressed with facility management on at least one other occasion when R1 first moved into the facility in February 2022. A review of outside source records submitted during the investigation and multiple interviews with staff and outside sources confirmed R1 had a condition known as Scatolia (fecal digging and smearing, a common condition with dementia patients). R1’s hygiene care plan required R1’s hands to be thoroughly washed and brushed underneath the nails as part of regular incontinence care. Facility management acknowledged that the incident occurred despite their effort to meet R1’s hygiene needs. After the incident occurred, facility management reminded staff and provided additional training to ensure R1’s hygiene needs continued to be met. In addition, facility management coordinated efforts with outside sources to ensure R1’s nails were kept trimmed. (continue on LIC9099C) Continue from LIC9099C) It was also alleged that staff did not provide quality food. It was specifically alleged that R1 would often be served the same meal multiple times on the same week and/or the same day. Outside sources indicated that on May 16, 2023, during a visit to the facility, they observed that R1 was going to have lentil soup for dinner. According to outside sources, R1 had lentil soup for lunch earlier the same day, and on May 15, 2023, R1 had lentil soup as well. On May 18, 2023, it was observed in the refrigerator a container 1/2 full with lentil soup. Staff confirmed that it was left over lentil soup that had been cooked earlier in the week. A review of evidence submitted during the investigation and multiple interviews with staff and outside sources confirmed that R1 had lentil soup multiple times for two consecutive days. Multiple interviews with staff and outside sources indicated that although not standard practice, at times staff would cook large quantities of certain meals for multiple days. The Department has investigated the above-mentioned allegations and has found that there was sufficient evidence to corroborate the above allegations. Therefore, these allegations are deemed to be substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies were cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations and are listed on LIC 9099-D. A plan of corrections was developed with Administrator, Tapia. An exit interview was conducted with Caregiver, Perez and Administrator, Tapia, and a copy of this report, Confidential Name List (LIC 811), along with Licensee/Appeal Rights (LIC 9058 03/22) were provided at the conclusion of the visit. (Continue from LIC9099A) According to S2, there had been a change to increase the dosage and they were waiting for the new order to update “Synkwise” (Electronic Medication Administration Record system). However, during staff interviews, management indicated that the change in medication caused confusion among the staff, but that the medication continued to be administered as prescribed. When the new order came in it was immediately updated in Synkwise. A review of medication records for the April and May 2023 periods indicated the medication was an active medication. However, there were multiple dates with missing recordings. The staff involved, S2, indicated that they had administered the medication as prescribed, but had failed to record it on Synkwise. During regular medication records review, there was no unaccounted medication. Multiple interviews with outside sources did not disclose any corroborating evidence that medication was not administered as prescribed. The Department has investigated the allegation and has found that there was insufficient evidence to corroborate the above allegation. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, this allegation is deemed to be unsubstantiated. An exit interview was conducted with Caregiver, Perez and Administrator, Tapia, and a copy of this report, Confidential Name List (LIC 811), along with Licensee/Appeal Rights (LIC 9058 03/22) were provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jul 18, 2023 · control 08-AS-20230515155751

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(7) · Plan of correction due date: Aug 18, 2023

87555(b)(7) General Food Service Requirements. Modified diets prescribed by a resident’s physician as a medical necessity shall be provided. This requirement was not met as evidenced by: Based on observations, interviews, and records review, the licensee did not ensure that diets prescribed as a medical necessity was provided to R1. This posed a potential health risk to one of four residents in care.the state’s words, verbatim · CDSS document, Jul 18, 2023

Plan of correction: Licensee agreed to read and conduct additional in-service training with staff on the regulations pertaining to food service and modified diets to ensure residents' care plans continue to be met. Proof of training documentation will be submitted to CCL by due date, 8/18/2023.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Aug 18, 2023

87464(f)(4) Basic Services Basic services shall at a minimum include: Personal assistance and care as needed by the resident …… with those activities of daily living. This requirement was not met as evidenced by: Based on observations, interviews, and records review, the licensee did not ensure that R1’s hygiene needs were met. This posed a potential health risk to one of four residents in care.the state’s words, verbatim · CDSS document, Jul 18, 2023

Plan of correction: Licensee agreed to read and conduct additional in-service training with staff on the regulations pertaining to basic services. Proof of training documentation will be submitted to CCL by due date, 8/18/2023.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(5) · Plan of correction due date: Aug 18, 2023

87555(b)(5) General Food Service Requirements Meals shall consist of an appropriate variety of foods… this requirement was not met as evidenced by: Based on observations, interviews, and records review, the licensee did not ensure that meals provided to R1 consisted of a variety of foods. This posed a potential health risk to one of four residents in care.the state’s words, verbatim · CDSS document, Jul 18, 2023

Plan of correction: Licensee agreed to read and provide additional in-service training to all staff on the regulations pertaining to food service requirements. Proof of trainings will be submitted to CCL by POC date of 8/18/2023.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced case management visit at the facility. LPA was greeted at the front entrance by Caregiver, Katia Perez and granted entry after identifying herself. LPA explained the purpose of the visit to Licensee, Patricia Tapia. The purpose of this visit was to discuss the facility’s current 30 Day Eviction Notice. During today’s visit, LPA Garcia-Centeno went over the 30 day eviction notice with Licensee, Tapia. An exit interview was conducted with Licensee, Tapia a copy of this report, and Licensee/Appeals Rights (LIC 9058 01/16) was provided to Licensee.the state’s words, verbatim · CDSS document, May 18, 2023

Allegation investigated: Licensee did not provide responsible party with a refund

Licensing Program Analyst (LPA) Elizabeth Hamilton conducted an unannounced complaint investigation visit at the facility. LPA was greeted at the front entrance by Caregiver, Maria Labra and granted entry after identifying herself. LPA Hamilton explained the purpose of the visit was to deliver findings for the above allegation to Licensee, Patricia Tapia. On June 14, 2022, it was alleged that Licensee did not provide responsible party with a refund after the death of a resident. Interviews with staff and outside sources revealed Resident 1’s (R1 – See LIC 809 Confidential Names List) Responsible Party (RP) paid in advance for services for May 2022 April 30, 2022. Records reviewed confirmed the May 2022 payment in the amount of $5,000.00. R1 passed away under hospice care on May 19th 2022. Substantiated Interviews with staff and outside sources revealed that after R1 passed away on May 19, 2022 at the facility, all their personal belongings were removed the same day by RP. The items that remained in R1’s room at the facility included; a wheelchair, shower chair, walker, hospital bed and oxygen tank, all supplied by a hospice agency as part of the agreed-upon hospice plan of care. The hospice agency that was under contract with R1 at the time of their death removed all items except the hospital bed and oxygen tank the same day, May 19, 2022. The hospital bed and the oxygen tank that had been provided by the previously contracted hospice agency were not removed until June 15, 2022 by the supplier due to delays in communication between the facility and both outside agencies. Although the hospice items remained at the facility for almost four weeks, they were not personal property nor the responsibility of the resident or resident’s responsible parties. The Department has investigated the allegation of Licensee did not provide responsible party with a refund. Based on evidence obtained, the allegation is substantiated which means that the allegation is valid because the preponderance of the evidence standard has been met. A deficiency is cited in accordance of California Code of Regulations, Title 22, Division 6 Chapter 8, and listed on the 9099D. An exit interview was conducted with Licesenee, Tapia a copy of this report, confidential names list, LIC 9099D and Licensee/Appeals Rights (LIC 9058 01/16) was provided to Licensee.the state’s words, verbatim · CDSS document, Jun 28, 2022 · control 08-AS-20220614141111

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.652 · Plan of correction due date: Jun 28, 2022

H&SC 1569.652(c) A refund of any fees paid in advance ... after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, ... if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed. This requirement was not met as evidenced by: Based on interviews and record reviews the licensee did not issue a refund to the responsible party within 15 days after R1’s personal property was removed. This posed a potential personal rights risk to one out of three residents in carethe state’s words, verbatim · CDSS document, Jun 28, 2022

Plan of correction: Licensee stated they will pay R1’s responsible party’s refund by July 11, 2022.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Elizabeth Hamilton conducted an unannounced case management visit at the facility. LPA was greeted at the front entrance by Caregiver, Maria Largo and granted entry after identifying herself. LPA Hamilton explained the purpose of the visit to Licensee, Patricia Tapia. The purpose of this visit was to discuss the facility’s current admissions agreement. During today’s visit, LPA Hamilton went over the refund section of the admissions agreement with Licensee, Tapia as required information was not included per Title 22 regulations. A deficiency was cited during today's visit. See LIC 809D page for citation and plan of correction. An exit interview was conducted with Licensee, Tapia a copy of this report, LIC 809D and Licensee/Appeals Rights (LIC 9058 01/16) was provided to Licensee.the state’s words, verbatim · CDSS document, Jun 28, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(5)(A) · Plan of correction due date: Jun 28, 2022

(5) Refund conditions. (A)Facility policy concerning refunds, including the conditions under which a refund for advanced monthly fees will be returned in the event of a resident’s death pursuant to Health and Safety Code section 1569.652. Based on interviews and record reviews the licensee did not include refund conditions in the event of a resident’s death. This posed a potential personal rights risk to one out of three residents in care.the state’s words, verbatim · CDSS document, Jun 28, 2022

Plan of correction: Licensee stated they will submit a revised Admissions Agreement to the Department by July 12, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced Required 1 - Year Visit. LPA was greeted by staff Maria Isabel Labra, identified herself, and discussed the purpose with Administrator, Patricia Tapia. All staff present have a current criminal record clearance. LPA conducted a tour with Administrator. In accordance with the Department’s Infection Control program, LPA provided technical assistance and observed and evaluated the facility's implementation of their COVID-19 Mitigation Plan (LIC 808). LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff and visitors; a sign-in policy enacted for all visitors; signs posted at facility entrance with the facility’s visitor policy, and signs throughout the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing; face coverings worn by staff; hand sanitizer/hand washing stations readily available; a designated visitation area; emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of PPE (Personal Protective Equipment). Based on observations, the facility is in compliance with and has implemented infection control practices as outlined in its Mitigation Plan (LIC 808). No deficiencies were observed during today's visit. An exit interview was conducted with Administrator Patricia Tapia, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided via E-mail. Email receipt confirmation will confirm receipt of this report.the state’s words, verbatim · CDSS document, Dec 13, 2021

Type of visit: Case Management - Other

Licensing Program Manager (LPM), John Rante and LIcensing Program Analyst (LPA), Marisela Garcia- Ceteno conducted a Case Management visit regarding an increase in capacity application. LPM and LPA identified themselves and discussed the purpose of the visit with Licensee, Patricia Tapia and Administrator, Vanessa Nunez. Licensees applied for an increase in capacity from four (4) ambulatory residents to six (6) non-ambulatory residents. There is an approved Fire Clearance dated 06/01/2021 for the increase in capacity and non-ambulatory status. As of today, there are no residents in care. LPM and LPA toured the facility and a had a discussion with the licensees regarding operation. LPM and LPA toured the physical plant and observed resident accommodations including furnishings, linens and personal hygiene items; resident bathrooms are equipped with cleaning products and paper towels; toxic substances are stored in a locked cabinet in the garage; medication storage and administration logs are to be located in a locked cabinet; sufficient space to conduct activities was present; facility posting requirements were present in a common area; the facility administrators certification was current; no pool or other body of water is present on the facility grounds; per the Administrator there are no guns, weapons or ammunition located on the property. Discussed with Administrator Tapia continuing operation requirements, record keeping and physical plant compliance. No deficiencies were issued during this visit. An exit interview was conducted with Licensee, Patricia Tapia, and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided to the Administrator via email. An electronic read receipt confirmation was requested to be sent by Administrator, Tapia upon receipt of the documents.the state’s words, verbatim · CDSS document, Aug 17, 2021