Victorian Manor

Type of visit: Case Management - Incident

In response to Incident Report dated 8/2/23--submitted to CCLD on 8/8/23--regarding client #1, LPA Jeung met with business office manager. Physician's Report dated 6/2021 and Needs and Services Plan dated 2/2023 were submitted to CCLD and reviewed. Deficiencies of the California Code of Regulations, Title 22, are cited on a following page.the state’s words, verbatim · CDSS document, Oct 2, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(4) · Plan of correction due date: Oct 9, 2023

CARE OF PERSONS WITH DEMENTIA Licensees who accept and retain residents with dementia shall be responsible for ensuring there is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement was not met, as staff did not adequately supervise client on 8/3/23 when he eloped from facility. Licensee failed to ensure client's safety, which posed a potential health, safety or personla rights risk to clients in care.the state’s words, verbatim · CDSS document, Oct 2, 2023

Plan of correction: Plan/proof of correction to be submitted to CCLD BY DUE DATE, to ensure that this or similar incident is not repeated.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87705(c)(5)(A) · Plan of correction due date: Oct 9, 2023

CARE OF PERSONS WITH DEMENTIA Each resident with dementia shall have an annual medical assessment... and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. When any medical assessment, appraisal, or observation indicates that the resident’s dementia care needs have changed, corresponding changes shall be made in the care and supervision... This requirement was not met, as MD report is over 2 years old & appraisal does not adequately address wandering behavior.the state’s words, verbatim · CDSS document, Oct 2, 2023

Plan of correction: Plan/proof of correction shall be developed and submitted to CCLD BY DUE DATE. This shall include updated MD report and Needs and Services Plan.

Allegation investigated: Resident is being illegally evicted.

On 09/08/23, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit to deliver findings for the above allegation. LPA met with Administrator, Ana Pacheco and explained the purpose of today's visit. Regarding the allegation of resident (R1) being illegally evicted. Reporting party (RP) received a letter of immediate eviction from the facility. LPA confirmed that the facility sent out a letter stating immediate eviction of R1. LPA also interviewed Administrator and and a copy was provided. Based on record reviews, the reassessment of R1 determined that the facility is not able to provide the level of care that R1 needs. While an eviction is warranted, the facility gave an immediate eviction notice, per Title 22, a 30-day notice to R1 is required. Based on interviews and record reviews the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with Administrator. A copy of this report and the Appeal Rights are provided. Substantiatedthe state’s words, verbatim · CDSS document, Sep 8, 2023 · control 14-AS-20230829093022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87224(a) · Plan of correction due date: Sep 9, 2023

87224(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5). This requirement was not met as evidenced by : Based on interviews and record reviews the facility gave an immediate eviction notice, per Title 22, a 30-day notice to R1 is required which poses an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 8, 2023

Plan of correction: Licensee shall amend eviction notice that provides 30 days from day letter is sent. Develop a plan and to ensure eviction procedures are followed in section 87224. Licensee to submit POC to Licensing by POC due date

Allegation investigated: Staff handled resident in a rough manner Staff do not ensure that resident is adequately fed Food served to resident is cold

On 7/5/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20230616164015. LPA Han met with care coordinator and administrator and explained the purpose of the visit. Regarding to allegation of - staff handled resident in a rough manner- there is no additional information forthcoming from the complainant and the co-complainant. However during the initial reporting, the complainant and the co-complainant stated that resident-in-question (R1) experienced aggressive staff who were not gentle during care. As part of the investigation, LPA reviewed resident records, reviewed facility staff training records, interviewed R1, interviewed administrator and facility staff. Unsubstantiated LPA interviewed R1 who described staff roughness and aggression as they failed to listen to R1 when R1 asked them to slow down during care and they did not explain what they were doing resulted R1 feeling unsafe, and uncomfortable. However, R1 reported that improvements were made recently. LPA interviewed administrator who denied the allegation and stated that he/she met with R1 and R1 did not expressed facility staff was rough and/or was abusive. However, R1 reported that staff did not explain what they were doing during care which resulted R1 feeling scared especially due to R1's poor vision. The administrator also stated that he/she met with R1 and developed a plan to remind staff of R1's health condition and to explain what they were doing while providing care to R1. LPA interviewed six facility staff who were assigned to R1 on the AM and PM shifts and all of them denied being rough and aggressive towards R1. They stated that R1 would get extremely fearful and scared during care despite their communication while providing care. LPA interviewed 3 residents and 1 family member and all of them reported that facility staff is respectful, they provided them with the care that they or their loved one required and they have not experienced and/or witnessed staff being aggressive and rough. During the visit, LPA was provided with 2 copies of R1's needs and services plans; one did not reflect resident's current health condition and the other one did. According to facility director, the needs and services plan that reflects R1's current health condition was updated during LPA's visit and acknowledged that it should have been updated it when the facility was informed in May 2023 by Institute On Aging of R1's change in health condition. After the investigation, this allegation is deemed to be unsubstantiated as the administrator has already met with R1 and resolved the allegation of staff was rough and aggressive. However, facility failed to update R1's needs and services plan to reflect R1's current health condition, This deficiencies will be cited on LIC809 and LIC809D under Case Management. Regarding to the allegation of staff do not ensure that resident is adequately fed, there is no additional information forthcoming from the complainant. However, during the initial reporting, the complainant stated that no one assisted R1 with feeding. As part of the investigation, LPA interviewed R1, and administrator. According to R1, facility staff is assisting R1 with feeding now but it was difficult in the past, however, it has been resolved. LPA interviewed the administrator who denied the allegation and stated that R1 did not required assistance with feeding upon admission. However, R1's vision declined resulted assistance with feeding started a couple of months ago. LPA interviewed 6 facility staff who were assigned to R1 on the AM or PM shift and all of them reported that they fed R1 during meals. They also reported that on most days, R1's intake was low so they had to go back and forth to encourage R1 to eat more. After the investigation, this allegation is deemed to be unsubstantiated. Regarding to allegation of- food served to resident is cold- there is no additional information forthcoming from the complainant and the co-complainant. However, during the initial report, the complainant stated that no one fed R1 resulted R1 ate cold food. As part of the investigation, LPA interviewed R1, facility staff, residents and family member. According to R1, R1 was served cold food but staff warmed it up except for one time. LPA interviewed facility staff who stated that R1 is a slower eater with poor appetite so they fed R1 at R1's paste. They acknowledged that R1's food would get cold at times but when R1 requested it to be warmed up, they proceeded with that request. LPA interviewed 3 residents and a family member and all of them stated that they did not have any problems with the temperature of their meals or their loved one's meals. If they wanted it to be warmer, they asked staff to heat it up and they did it. After the investigation, this allegation is deemed to be unsubstantiated. Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. This report is reviewed and discussed with Care Coordinator and administrator. and a copy is provided.the state’s words, verbatim · CDSS document, Jul 5, 2023 · control 14-AS-20230616164015

Type of visit: Case Management - Deficiencies

On 7/5/2023, Licensing Program Analysts (LPA) Murial Han conducted an unannounced case management visit to deliver the findings in reference to complaint # 14-AS-20230616164015. LPA met with Care Coordinator and administrator and explained the purpose of the visit. During the initial complaint visit on 6/21/2023, LPA was informed resident #1 (R1) was transferred to the hospital due to an incident, and the administrator provided a copy of the incident report (LIC624) stating that R1 was transferred to the hospital on 6/5/2023. However, the report did not indicate that the incident was reported to CCLD, and LTCO. In addition, there is no record at CCLD that this incident was reported by the facility. During the course of the complaint investigation, LPA observed the facility was notified by Institute on Aging in May 2023 of R1's change in health condition. However, R1's needs and services plan was updated during LPA's visit on 6/21/2023. According to facility director, R1's needs and services plan should have been updated in May 2023 when facility was notified by Institute On Aging of R1's changes in health condition. In addition, LPA observed R1's needs and services plan was not signed and dated by the resident, responsible party and facility representatives. LPA interviewed R1 who stated that he/she did not know what a needs and services plan was and he/she was not part of the care planning process. Deficient is cited under California Code of Regulations, Title, 22 cited on the LIC809D. Failure to correct the deficiencies may result in civil penalties. This report is reviewed and discussed with care coordinator and administrator. a copy is provided and appeal rights.the state’s words, verbatim · CDSS document, Jul 5, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Jul 14, 2023

87463 Reappraisals..(a) The pre-admission appraisal shall be updated,.. The reappraisals shall document changes in the resident's physical,.... This requirement is not met as evidenced by R1 had a change in health condition and needs and services plan was not updated in a timely fashion which posed a potential health risks to resident in care.the state’s words, verbatim · CDSS document, Jul 5, 2023

Plan of correction: The administrator/ licensee will develop a plan to ensure resident's needs and service plans are current reflecting resident's needs and health condition. This plan shall include staff training. The administrator will provide a copy of the plan and a copy of the staff training record to CCL by the plan of correction due date of 7/14/2023.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87468.2(a)(7) · Plan of correction due date: Jul 14, 2023

87468.2Additional Personal Rights of Residents in Privately Operated Facilities..(a)In addition to the rights listed in Section 87468.1,..(7) To fully participate in planning their care, including the right to attend and participate in meetings or communications regarding care and services to be provided,..This requirement is not met as evidenced by R1's needs and services plan was updated on 6/21/2023, however, the signature page indicating it was reviewed by R1 was blank which posed a potential health risk to resident in care.the state’s words, verbatim · CDSS document, Jul 5, 2023

Plan of correction: The administrator will review the regulation and develop a plan to ensure residents and/or responsible parties are part of the care planning process and the care plan shall be reviewed and signed by all required reviewers. The plan shall include staff education. The administrator will provide a copy of such plan and a copy of staff education record to CCL by the plan of correction due date of 7/14/2023.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Jul 14, 2023

87211 Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports as the Department...(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence.. The requirement is not met as evidenced by resident #1 was transferred to the hospital on 6/5/2023 and it was not reported to CCLD.the state’s words, verbatim · CDSS document, Jul 5, 2023

Plan of correction: The licensee/administrator will develop a plan to ensure compliance and provide in-service to facility staff. The licensee/administrator will provide a copy of the plan and in-service records to CCL by 7/14/2023.

Allegation investigated: Staff did not properly address resident being burned by another resident Facility staff are not meeting toileting needs of resident Facility lacks adequate staffing to meet residents care needs

On 1/27/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20220926122653. LPA Han met with administrator and explained the purpose of the visit. Regarding to allegation of- staff did not properly address resident being burned by another resident, there was no additional details forthcoming from the reporting party, however, during the initial reporting, the reporting party stated that resident #1 (R1) was severely burned by another resident. The administrator denied the above allegation and stated that when the administrator was informed of such incident, the administrator instructed resident care coordinator to assess R1. The resident care coordinator and another staff went to R1's room and R1 was combative and agitated and refused to be assessed, however, R1 reported that the incident as another resident (R2) followed R1 into R1's room, touched R1's belongings and when R1 asked R2 to stop, R2 grabbed the hot water that R1 was holding and threw it on R1. Unsubstantiated As part of the reporting requirement, the facility reported it to R1's physician , Long Term Care Ombudsman and R1's responsible party; subsequently, R1 was seen by R1's physician on the following day. The facility also attempted to collect more details from staff, but none of them had knowledge of such incident as it was witnessed. As prevention, facility offered R1 to move to another room on a different floor but R1 did not accept the offer. However, the facility was able to move R2 after a discussion with the responsible party. Since the room transfer, there was no further incidences. Based on the documents provided by the facility, LPA observed this incident was reported on 11/20/2020 (incident happened on 11/19/2020) via LIC 624 (Unusual Incident/Injury Report) indicating that it was reported to R1's responsible party, Long Term Care Ombudsman and R1 was seen by On-Lok Clinic. In addition, a SOC 341 ( Report of Suspected Dependent Adult/Elder Abuse) was also completed. Based on interviews, and record reviews during the course of the investigation, this allegation is deemed to be unsubstantiated. Regarding to allegation of- facility staff are not meeting toileting needs of resident and facility lacks adequate staffing to meet resident's care needs, there is not additional information forthcoming from the reporting party. However, during the initial reporting, the reporting party stated that facility staff failed to change R1's soiled diaper and asked R1 to poop in R1's diaper. As part of the investigation, LPA interviewed R1 who stated that it took the staff hours to change R1's soiled diaper. The administrator and the resident care coordinator denied the above allegation and stated that every morning before night shift staff ends their shift at 6:30am, they would clean, change, provide a bed bath and get R1 into a wheelchair to start R1's day. In addition, they have not heard any complaints from R1, the responsible party and the physician regarding this allegation. Furthermore, the administrator stated that the facility recently added additional staff to anticipate new residents from Laguna Honda. LPA interviewed staff #1 (S1) who stated that night shift staff would clean, change and get R1 ready for the day and when S1 arrived at work, R1 was already cleaned and up in a wheelchair. S1 was not aware of such allegation. In addition, S1 stated that staff assisted R1 to the toilet during the day and R1 performed self-care after toileting unless R1 requested for assistance. LPA interviewed 3 other residents regarding to the care that they received by staff including but not limiting to toileting needs and all of them reported that they were satisfied with the care that they received and staff was attentive to their needs. During the initial visit, LPA observed residents to be cleaned, comfortable and LPA did not smell any unpleasant odor at the facility. Based on observation and interviews during the course of the investigation, this allegation is deemed to be unsubstantiated. Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. LPA observed R1's medication administration record that indicated this specific medication was ordered for 5 days and 4x daily and the medication administration record indicated that it was properly administered by facility staff. Based on record review, and interviews during the course of the investigation, this allegation is deemed to be unfounded. Regrading to allegation of facility staff are retaliating against the resident for filing a complaint- there is no additional information forthcoming from the reporting party and R1. As part of the investigation, LPA interviewed the administrator who denied the allegation and stated that facility encouraged residents and their responsible parties to contact the advocates such as the Long Term Care Ombudsman and the Long Term Care Ombudsman information is posted in the facility. Therefore, this allegation is deemed to be unfounded as there is no details provided. . Regarding to staff did not prevent another resident from entering resident's room- there is no additional information forthcoming from the reporting party. The administrator denied the allegation and stated that this incident was not witnessed by facility staff and if it was, staff would have discouraged R2 from entering R1's room. LPA interviewed R1 who stated that when R2 followed R1 into R1's room, there was no staff around to stop R2 from doing that. Based on interviews during the course of the investigation, this allegation is deemed to be unfounded. Regarding to allegation of- staff does not treat resident with respect, there is no additional information forthcoming from the reporting party. As part of the investigation, LPA interviewed other residents who stated that facility staff is attentive, they treat residents with respect and dignity. Based on interviews during the course of the investigation, this allegation is deemed to be unfounded. Based on the above information, the Department has found that this allegation to be UNFOUNDED, meaning that this allegation was false, could not have happened and/or is without a reasonable basis.the state’s words, verbatim · CDSS document, Jan 27, 2023 · control 14-AS-20220926122653

Type of visit: Required - 1 Year

On 1/27/2023, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA observed COVID-19 signs posted by the entrance. LPA was greeted by the Administrator, Ana Pacheco. LPA explained the purpose of the visit and LPA was screened at the front entrance. LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident and staff daily monitoring records (staff is being screened by the receptionist when they arrive and when they leave), containment strategies( the facility has reserved a private room with a private restroom and equipped with a PPE supply cart). PPE supply and the environmental cleaning supply are adequate, bathrooms are equipped with liquid soap, paper towels, hand washing instruction is posted by the hand washing stations. There are 2 dining rooms on the 2nd and 3rd floor, 1 nursing station on each floor and medication room is located on the 2nd floor. COVID-19 signs observed to be posted around the facility. The beds in the shared bedrooms are 6"feet apart. LPA observed COVID-19 signs are posted in the staff lounge. There are hand sanitizer dispensers installed in front of each elevator and in the nursing stations. The high touched areas are being disinfected every hour including the public phone on both floors. Medications, toxins and sharps are stored appropriately and inaccessible to resident; first aide kit inspected and complete; a comfortable temperature is maintained, lighting is sufficient for comfort. No deficiency cited today. This report is reviewed and discussed with the Administrator, Ana Pacheco. A copy is provided.the state’s words, verbatim · CDSS document, Jan 27, 2023

Type of visit: Case Management - Health Checks

On 8/10/2022. Licensing Program Analyst (LPA) Murial Han conducted an unannounced health and welfare check. LPA met with the administrator and explained the purpose of today's visit. Today's visit is to follow-up on the health and welfare check that was conducted on 7/12/2022 concerning 3 residents who were admitted from a skilled nursing facility. The administrator reported that since LPA's last visit, the facility has not admitted any additional residents from the skilled nursing facility. However, the facility is anticipating to take more and the facility will follow the pre-admission process prior to admitting new residents such as reviewing the medical records, conducting an on-site assessment, completing the pre-admission appraisal and the LIC602 (Physician's Report). During today's visit, LPA met with the 3 residents and they stated that they are doing well. No deficient cited today. This report is reviewed and discussed with the administrator. A copy is provided.the state’s words, verbatim · CDSS document, Aug 10, 2022

Type of visit: Case Management - Health Checks

On 7/12/2022, Licensing Program Analyst (LPA), Murial Han conducted an unannounced Health and Welfare check as the facility admitted 3 residents from a skilled nursing facility and is anticipating to admit additional residents from the same facility . LPA met with the administrator and explained the purpose of today's visit. According to the administrator, to ensure residents are appropriate for admission, the facility requests and reviews medical records, and conducts an on-site/ in-person assessment prior to admission. The administrator also stated that the facility has agreed to take additional residents from the same facility pending final review of their medical records. Furthermore, the administrator stated that the facility has increased its staffing level to accommodate the additional residents. During today's visit, LPA Han reviewed and collected these documents: Identification and Emergency Information, LIC 602 (Physician's Orders), Preplacement Appraisal Information, Service Plan, Medication List and Staffing Assignments/Work Schedule. In addition, LPA interviewed the 3 residents and they appeared with bright affect, they stated that the facility is providing the care that they needed but they need time to adjust as this is a new environment for them. LPA requested additional documents to be submitted by 7/15/2022: - Direct Care Staff Training Records - Updated LIC500 No deficiency today. This report is reviewed with the administrator. A copy is provided.the state’s words, verbatim · CDSS document, Jul 12, 2022

Type of visit: Required - 1 Year

On 12/2/2021, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA observed COVID-19 signs posted by the entrance. LPA was greeted by the Administrator, Ana Pacheco. LPA explained the purpose of the visit and LPA was screened at the front entrance. LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident and staff daily monitoring records (staff is being screened by the receptionist when they arrive and when they leave), containment strategies( the facility has reserved a private room with a private restroom and equipped with a PPE supply cart). PPE supply and the environmental cleaning supply are adequate, bathrooms are equipped with liquid soap, paper towels, hand washing instruction is posted by the hand washing stations and LPA recommended to replace some of the trash cans with the foot operated lids. COVID-19 signs observed to be posted around the facility. LPA observed many residents wearing face masks. The tables in the dinning rooms are spaced out at least 6" apart from each other. The beds in the shared bedrooms are 6"feet apart. The tables in the staff lounge is apart and LPA observed COVID-19 signs are posted. There are hand sanitizer dispensers installed in front of each elevator and in the nursing stations. The high touched areas are being disinfected every hour including the public phone on both floors. Medications, toxins and sharps are stored appropriately and inaccessible to resident, a comfortable temperature is maintained, lighting is sufficient for comfort. During today's inspection, LPA Han requested for the following documents to be submitted to the Regional Office by 12/7/2021: - Updated Administrator Certification - LIC 308 (Designation of Administrative Responsibility) - LIC 610E (Emergency Disaster Plan) - LIC 500 (Personnel Report) No deficiency cited today. This report is reviewed and discussed with the Administrator, Ana Pacheco A copy is provided.the state’s words, verbatim · CDSS document, Dec 2, 2021