Wyndham Residence

Allegation investigated: Questionable death

Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to deliver final findings for the above allegations. During today’s visit, LPA De Leon met with and explained the reason for the visit. On 01/26/2023, the Department received a complaint regarding allegations of questionable death of two residents and staff did not provide proper medication assistance to resident in care. It was alleged that Staff #1 (S1) was providing morphine to Resident #1 (R1) and Resident #2 (R2) and S1 is not able to do so. It was alleged that S1 provided morphine to R1 when it was not needed and R1 passed away within days of getting morphine medication, and the reporting believed R1 was not getting comfort medications from hospice. The complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Romelia Munoz. Continued 9099-C pages Unfounded The LPA requested the following records for R1 and R2: LIC 602 Physicians Reports, Appraisal Needs and Services Plan (ANS), Hospice Admit records, Hospice Agency Name and phone numbers, Hospice Care Plans, Medication Administration Records (MAR) for 10/2022-11/2022, Centrally Stored Medication and Destruction Records (CSMDR), Incident Reports, Death Reports, Death Certificates, Call pendant logs for 10/2022-11/2022, Staff and Hospice Notes 09/2022-11/2022, Resident Roster for 11/2022 and 01/2023 with telephone numbers, Staff and Hospice notes for 09/2022-11/2022, Staff 1 (S1) hire date at the facility and hire date of last promotion, Staff Roster with telephone numbers for 11/2022 and 01/2023. The LPA informed Administrator that the complaint was referred to the Community Care Licensing (CCL) Investigation Branch (IB). On 03/23/2023 Investigator Munoz contacted the Reporting Party (RP); on 03/24/2023, from approximately 1:00pm to 1:15pm, contacted facility staff to schedule in-person interviews; on 03/27/2023, from approximately 9:30am to 10:10am, conducted interviews with staff; on 04/05/2023, at approximately 2:30pm, with RP; on 04/06/2023, from approximately 4:00pm to 4:05pm, left message for S1 and interviewed Administrator; on 04/11/2023, at approximately 1:40pm, left message for S1; and on 04/14/2023, at approximately 11:39am, interviewed S1. In addition, the investigator reviewed Wilshire Hospice Agency records related to R1 and R2, and facility file documents relevant to the investigation. The Wilshire Hospice Agency records revealed that on 07/15/2022, R1 was admitted in hospice care and given a life expectancy of six months or less for hypertensive heart with Chronic Kidney Disease. On that same day, R1 was prescribed morphine, .25ml for mild pain, 0.5ml for moderate and 1ml for severe pain to be given every hour or as needed. The death certificate listed the cause of death as Acute Cardiopulmonary Arrest, Congestive Heart Failure, Hypertensive Heart Disease. There were no indications R1’s medications were not given as prescribed. On 12/30/2021, R2 was admitted in hospice care and given a life expectancy of six months or less if illness runs normal course. On this same day, R2 was prescribed morphine to be taken every hour or as needed for pain. R2 was prescribed .25ml for mild pain, 0.5ml for moderate and 1.ml for severe pain. The death certificate listed the cause of death as Acute Cardiopulmonary Arrest, Congestive Heart Failure, Hypertensive Heart Disease. There were no indications R2’s medications were not given as prescribed. Continued 9099-C pages Information obtained through interviews revealed the hospice nurses individually prepared the syringe with the appropriate dosage of prescribed morphine for R1 and R2. The morphine is usually provided every hour or as needed. The resident is assisted with the self-administration of medication via a syringe provided orally through the resident’s mouth. Training records reviewed revealed that S1 received “16 hours hand on training before assisting residents with self-administration of medications and 8 hours of instruction completed with a qualified trainer using written materials, discussions, and watching video demonstrations”. This was completed on 10/20/2022 and signed by Corina Segundo, facility Licensed Vocational Nurse (LVN). Based on statements and documentation provided, the allegation is Unsubstantiated at this time. Exit interview conducted, a copy of this report issued. On 01/27/2023, from 10:13am to 3:38pm, Licensing Program Analyst (LPA) Rachael De Leon conducted a (24 hour) 10-day complaint visit to the facility above. LPA De Leon met with the Administrator, Jodi Beltrama, and explained the purpose of the visit. The LPA requested the following records for R1 and R2: LIC 602 Physicians Reports, Appraisal Needs and Services Plan (ANS), Hospice Admit records, Hospice Agency Name and phone numbers, Hospice Care Plans, Medication Administration Records (MAR) for 10/2022-11/2022, Centrally Stored Medication and Destruction Records (CSMDR), Incident Reports, Death Reports, Death Certificates, Call pendant logs for 10/2022-11/2022, Staff and Hospice Notes 09/2022-11/2022, Resident Roster for 11/2022 and 01/2023 with telephone numbers, Staff and Hospice notes for 09/2022-11/2022, Staff 1 (S1) hire date at the facility and hire date of last promotion, Staff Roster with telephone numbers for 11/2022 and 01/2023. The LPA informed Administrator that the complaint was referred to the Community Care Licensing (CCL) Investigation Branch (IB). On 03/23/2023 Investigator Munoz contacted the Reporting Party (RP); on 03/24/2023, from approximately 1:00pm to 1:15pm, contacted facility staff to schedule in-person interviews; on 03/27/2023, from approximately 9:30am to 10:10am, conducted interviews with staff; on 04/05/2023, at approximately 2:30pm, with RP; on 04/06/2023, from approximately 4:00pm to 4:05pm, left message for S1 and interviewed Administrator; on 04/11/2023, at approximately 1:40pm, left message for S1; and on 04/14/2023, at approximately 11:39am, interviewed S1. In addition, the investigator reviewed Wilshire Hospice Agency records related to R1 and R2, and facility file documents relevant to the investigation. The Wilshire Hospice Agency records revealed that on 07/15/2022, R1 was admitted in hospice care and given a life expectancy of six months or less for hypertensive heart with Chronic Kidney Disease. On that same day, R1 was prescribed morphine, .25ml for mild pain, 0.5ml for moderate and 1ml for severe pain to be given every hour or as needed. On 09/26/2022, R1 showed signs of early transition. Over the span of R1’s care R1’s physical health declined as R1 decreased oral intake. R1’s ambulation capability declined and eventually was lost. R1 sustained multiple falls and a week prior to R1’s death R1 obtained a skin tear from an unknown origin per the facility. R1’s wound was painful, non-healing, and needed to be medicated around the clock. R1 became bedbound, non-verbal and began sleeping majority of the day. R1 spent one day actively dying until R1 passed quickly and comfortably in their room. R1 died on 11/02/2022. The death certificate listed the cause of death as Acute Cardiopulmonary Arrest, Congestive Heart Failure, Hypertensive Heart Disease. Continued 9099-C pages On 12/30/2021, R2 was admitted in hospice care and given a life expectancy of six months or less if illness runs normal course. On this same day, R2 was prescribed morphine to be taken every hour or as needed for pain. R2 was prescribed .25ml for mild pain, 0.5ml for moderate and 1.ml for severe pain. R2 died on 11/23/2022. The death certificate listed the cause of death as Acute Cardiopulmonary Arrest, Congestive Heart Failure, Hypertensive Heart Disease. Information obtained through interviews revealed the hospice nurses individually prepared the syringe with the appropriate dosage of prescribed morphine for R1 and R2. The morphine is usually provided every hour or as needed. The resident is assisted with the self-administration of medication via a syringe provided orally through the resident’s mouth. Training records reviewed revealed that S1 received “16 hours hand on training before assisting residents with self-administration of medications and 8 hours of instruction completed with a qualified trainer using written materials, discussions, and watching video demonstrations”. This was completed on 10/20/2022 and signed by Corina Segundo, facility Licensed Vocational Nurse (LVN). Based on statements and documentation provided, the Department does not have sufficient evidence to determine that R1 and R2, both in hospice care, suffered a questionable death. The death certificate for R1 and R2 stated they died of natural causes. The staff member in question, S1, is certified and trained to assist with medications, including the morphine. The Reporting Party recanted their concerns upon confirmation that R1 and R2 were on hospice care and the Reporting Party does not believe S1 would purposely hurt a resident. Additionally, the hospice providers did not elevate any concerns regarding resident care. Therefore, the allegation Questionable Death is Unfounded at this time. A finding of unfounded means that the allegation is either false, could not have happened, and/or is without a reasonable basis. Exit interview conducted, a copy of this report issued.the state’s words, verbatim · CDSS document, Jul 17, 2023 · control 29-AS-20230126152418

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) De Leon arrived at 9:00 am to conducted a case management annual continuation visit to the facility above. LPA met Administrator Jodi Beltrama and explained the purpose of the visit. Staffing: The facility employes 38 staff and 1 Administrator. Staff records are kept confidential. LPA reviewed 5 random staff files. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Finger print clearance/Associations/exemptions. Administrator file was reviewed for Continuing Education requirements and current Administrator Certificate. Personnel Records & Training: The facility keeps confidential files for each staff member. LPA reviewed 5 staff training records for Initial and/or Annual Training Requirements of 20 plus hours meeting 8 hours of dementia training with all subjects covered over a 3 year period, 4 hours of hospice care, postural supports and restricted health condition and 8 hours of other training to include ADL's, resident characteristics, emergency preparedness policy and procedures, infection control requirements and Quarterly Disaster Drills. Staff handling medications had initial and/or annual training of 8 hours of medication training. Kitchen staff had training on facility policy and procedures for food handling and preparation as well as infection control requirements, some staff had food handler certificates. Trainers met the requirements to train staff with required information present in files. Hospice and Home Health care plans had training records on file. Incidental Medical & Dental: The facility has a medication room that is kept locked as well as two medication carts which are kept locked. Facility provides transportation to medical and dental appointments when needed. The medications records were reviewed and all residents in care had a Medication Administration Record (MAR) and a Centrally Stored Medication Destruction Record (CSMDR). LPA inspected medication cart for all prescription and PRN medications, Doctors orders and house medications for expiration dates. No medications labels were altered. LPA chose 1 random residents medications to review and all requirements were met and followed. The facility has a mini locked refrigerator for medication and an ice chest for emergency use. The facility has a red sharps container for disposal of syringes. Medication Destruct is done by the facility with Administrator and Wellness Director present. Exit interview conducted, No deficiencies cited, copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Jul 12, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) De Leon arrived at 9:30 am to conducted a 1 year annual visit to the facility above. LPA met Administrator Jodi Beltrama and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit: Infection Control: The facility has submitted a current Mitigation Plan, Infection Control Plan, Emergency Disaster Plan and provide plans to the department. The facility has a sign in and out binder for visitors at entry with hand sanitizer and symptom screening. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has EPA approved disinfectants spray and cleaners. The facility has trash bins with covers. The facility has a 30 day supply of PPE. New residents are tested and negative results received before residing in the facility. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE). All trash cans and waste baskets have tight fitting covers. Physical Plant & Environment Safety: The facility is a 58 bedroom and 58 bathroom currently occupying 52 residents and employs 38 staff. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has dual smoke and carbon monoxide detectors and sprinkler system. The lighting and lamps are sufficient for the use of the facility and for residents comfort. The facility kitchen is clean, safe and sanitary. The showers have non-skid textured floors. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The facility has a signal system in each residents room. The pathways are clear of any obstructions. Facility is well lit and equipped with hand railings where needed and around porches. Fire place has a screened covering. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care. The facility has sufficient space inside and outside for activities and visiting. The facility has a enclosed courtyard for resident use with plenty of shade. The facility has telephone and internet service for resident use. Operational Requirements: The facility has a current plan of operation and infection control plan on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on 05/01/2024. The facility is approved for a capacity of 72 Non-Ambulatory and has a current Hospice wavier granted for 15. Staffing: The facility employes 38 staff and 1 Administrator. Staff records are kept confidential. LPA will return at a later date to review staff files. Personnel Records & Training: The facility keeps confidential files for each staff member. LPA will return at a later date to review staff training records. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Five files were reviewed for signed Admission Agreements, Medical Assessments, LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights, and Safeguard for personal property and valuables. Pre-Admission appraisals are conducted on perspective residents before accepting them into care. The Facility does handle cash resources for some of the residents in care. The facility Surety bond is current. Facility does submit incident reports to the department when required. Resident Rights Information: All require postings were posted in the common area of the facility. Personal rights, Rights to Resident Council, Theft and Loss policy, and Non-discrimination notice. CCL Complaint poster and LTCO poster were posted in the common areas of facility. The current license along with CCL reports and PIN's were posted. Visitation policy is posted at entry. Internet is provided in each resident room for confidentiality and privacy. Planned Activities: The facility offers activities to all residents in care. The facility employs an Activities Director and a monthly calendar with all activities is posted. The facility also offers additional activities to include books, magazines, newspapers, television, daily walks, group discussions and communications, games and puzzles. The facility has a piano for resident use. The facility has sufficient space to allow for activities indoors and outdoors as well as an activity room. Food Service: The facility employs food service staff. The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the residents want them. Emergency supply of food and water is available. A menu is posted for residents in care. Modified diets prescribed by a physician are followed for those residents in care. Cleaning solutions and equipment are stored separately than food supply. Kitchen areas are kept clean and free from litter, rodents, vermin and insects. Kitchen staff are observed for personal hygiene and food sanitation practices. Incidental Medical & Dental: Facility provides transportation to medical and dental appointments when needed. The medications records were not reviewed. LPA will return to review medication records at a later date. Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. The fire extinguishers were charged and last inspected 10/18/2022. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency. Residents with Special Health Needs: The facility does not accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked or in accessible to residents in care. The facility does not have delayed egress. The facility does have residents with oxygen and required signs are posted. The facility has 7 hospice residents in care. Hospice care plans are kept on file and up to date. The facility does currently have 11 residents on Home Health services. Home Health services records are kept on file. LPA conducted interviews with 5 Residents and 1 Staff. LPA will return to complete staff interviews. Exit interview conducted and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Jun 30, 2023

Allegation investigated: Staff do not respond to resident's call light in a timely manner Staff did not have an Oxygen sign on the residents door

Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above to deliver final findings of the complaint allegations. LPA met with Administrator Jodi Beltrama and explained the purpose of the visit. LPA Olson conducted the initial 10-day complaint visit on 04/20/2022 from 11:00am to 1:40pm, LPA toured the facility, rooms, collected records and conducted interviews with staff at 11:00am, 12:30pm, and 12:45pm and residents. LPA De Leon conducted interviews with staff on 12/10/2022 at 11:17am, 11:40am, and 12:18pm. LPA conducted interviews with residents on 01/03/2023 at 2:39pm, 2:42pm, 3:22pm, 3:30pm and 3:46pm. LPA De Leon reviewed records on 01/03/2023 at 1:00pm. Continued 9099-C Substantiated On the allegation: Staff do not respond to resident's call light in a timely manner. LPA reviewed the call light/pendant records for R1, LPA found during the dates of 03/09/2022 to 04/05/2022. R1 had a total of 27 calls. 8 calls were over 10 minutes. The dates and length of those calls were 03/09/2022 for 10 minutes 31 seconds (10:31), 03/09/2022 for 15:48, 03/09/2022 for 35:18, 03/10/2022 for 12:04, 03/11/2022 for 41:13, 03/28/2022 for 10:27, 04/01/2022 for 29:36, and on 04/03/2022 for 40:36. Staff interviewed were not able to recall why those calls were not acknowledged or cleared timely. Staff interviews stated sometimes the call light/pendants were not working properly and/or if you walk-in on an emergency you need take care of that first then clear the call light/pendant after you helped the resident. Staff interviewed stated the facility was experiencing outbreaks of Covid, Outbreak of norovirus and were short staffed when the facility had call offs during this time. Interview with witness stated that R1 complained the call pendant was not being answered. Based on the evidence the allegation is deemed Substantiated at this time On the allegation: Staff did not have an Oxygen sign on the resident’s door. LPA Olson observed 1 resident room without an oxygen sign on the door. Witness stated they did not see an oxygen sign on the door when they were present at the facility. Staff stated they do have oxygen signs on the resident’s doors but there is one resident that takes the signs down. Staff stated they are now hanging the sign higher up so it cannot be taken down so easily. Based on the evidence the allegation is Substantiated at this time. Exit interview conducted, deficiencies cited, copy of report and appeal rights emailed to Administrator. On the allegation: Staff do not wear masks properly. LPA’s interviewed staff, residents and witness which revealed that all staff wear masks properly at the facility all the time. Masks are provided at entry of facility to all staff and visitors entering. LPA Olson observed masks being worn by all staff. LPA De Leon observed staff wearing masks. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time. On the allegation: Staff are not following COVID guidelines. LPA Olson conducted a visit and upon arrival she was screened for Covid-19 by front desk staff prior to entry into the facility, staff were wearing masks properly and signs for covid-19 were hung in the common areas. Residents stated the facility is cleaned and wiped down regularly. Staff stated the facility was cleaned and disinfected regularly, masks were mandatory, and everyone was following Covi-19 guidelines. Based on the lack of evidence the allegation is deemed Unsubstantiated at this time. On the allegation: Resident left in soiled diapers for an extended amount of time. LPA interviewed staff which revealed R1 was not on a care plan for incontinence care when R1 moved into the facility. R1 took care of R1’s own needs with little to no assistance. Staff completed rounds every 2 hours R1 had a change in condition in the beginning of April 2022 at which time R1 needed additional help with R1’s incontinent needs and briefs were necessary. R1 became bed bond on hospice services and went to 1-hour checks at that time. Hospice records recorded 1 incident of the resident being wet on hospice visit but no timeline was given to state this had been for an extended amount of time. R1’s medical records do not state any rashes or sores were present. Based on the lack of evidence this allegation is Unsubstantiated at this time. On the allegation: Resident's rooms are dirty. LPA interviewed staff, residents, and witness which revealed the facility was clean, the rooms were cleaned regularly by caregivers and housekeeping staff and the linens were changed weekly or more if needed. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time. On the allegation: Resident left on the floor for an extended amount of time. LPA interviewed staff, residents and witness which did not reveal anyone being left on the floor for an extended amount of time. Staff stated they do 2-hour checks for most Assisted Living residents some residents can be every hour and every 30 minutes due to being ill, declining health, hospice or being a fall risk. The staff stated the residents have a pendant to push if help is needed before the regular rounds are done. Staff stated they do not remember R1 being on the floor for an extended amount of time. Based on the lack of evidence the allegation is deemed Unsubstantiated at this time. On the allegation: Staff are not properly trained to work with residents. LPA interviewed Staff, Residents and witness which revealed the staff providing care to the residents do a good job and are trained properly on resident care. Staff training records reviewed; staff are meeting the training regulations. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of report emailed to the Administrator.the state’s words, verbatim · CDSS document, Jan 20, 2023 · control 29-AS-20220411100823

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jan 23, 2023

(f)Basic services shall at a minimum include: (1)Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).7464(f)(1) This requirement was not met as evidenced by: Based on record review the licensee did not comply with the regulation above. R1 pressed alarm pendant and waited 10-45 minutes for help on 8 occasions to receive services which posses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 20, 2023

Plan of correction: Administrator agreed to review all call systems to make sure they are all working properly, review pendant logs, emergency pull cords and telephone alarms for calls more then 15 minutes in duration and investigate why they are taking place and fix any issues discovered. Provide a plan going forward on how calls will be answered timely. Provide training to all staff on policy and procedures for answering calls timely and backup plans for calls to be answered when floor staff is busy and cannot provide assistance timely. Provide copy of plan and training to CCL.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87618(b)(3)(B) · Plan of correction due date: Jan 27, 2023

(b)In addition to Section 87611(b), the licensee shall be responsible for the following:(3)Ensuring that the use of oxygen equipment meets the following requirements: (B)"No Smoking-Oxygen in Use" signs shall be posted in the appropriate areas. This requirement was not met as evidenced by: Based on LPA observation the licensee did not comply with the regulation above. A resident room did not have an oxygen sign present which possess a potential safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 20, 2023

Plan of correction: Administrator agreed to review and train all staff on regulation 87618. Make sure a list of residents with oxygen is available to staff and that a sign is posted when required, and staff will monitor that the signs continue to be posted. Send proof of training to CCL

Allegation investigated: Illegal eviction Staff do not respond to resident's call light in a timely manner

Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above to deliver final findings of the complaint investigation. LPA met with Administrator Jodi Beltrama and explained the purpose of the visit. LPA De Leon conducted the initial 10-day complaint visit on 08/09/2021 at 2:30pm, interviewed staff and collected records. LPA De Leon conducted additional interviews on 08/11/2021 and on 12/06/2022 at 12:39pm. LPA De Leon reviewed records on 12/05/2022 and 12/06/2022. On the allegation: Illegal eviction. LPA De Leon conducted interviews with staff and witnesses which revealed a care conference regarding Resident 1 (R1) was held due to change in condition and frequent falls. Continued 9099-C Unsubstantiated Facility staff initiated the care conference with responsible parties (RP’s) of R1 due to concerns the facility had experienced with R1. The care conference was held and the RP’s agreed with a change in condition and relocation of R1. RP found placement with the help of the facility and hired movers to move R1 on 08/06/2021 and provided facility with this move out date. The facility did not evict or issue an eviction to the resident or the RP’s of the resident. R1 diagnosis (dx) did change and was updated on an LIC 602A Physicians report and given to the facility on or after 08/04/2021. R1’s new dx would have warranted an eviction by the facility as the facility would not have been able to meet R1’s needs, the RP had already given notice and made arrangements to move R1 out of the facility on 08/06/2021 so the Facility did not have to issue an eviction letter. Based on the evidence this allegation is deemed Unsubstantiated at this time. On the allegation: Staff do not respond to resident's call light in a timely manner. LPA requested records of R1’s call pendant and reviewed those records, The records indicated that between 06/11/2021 and 7/31/2021 R1’s pendant alarmed 27 times. Only 5 out of 27 pendant alarms were over 10 minutes. On those 4 occasions the call was acknowledged by staff within minutes and then cleared by staff within 10:05 minutes/seconds, 32:12, 18:28 and 18:38 minutes/seconds. One alarm call was over 4 hours due to the family taking the residents out of the facility and not leaving the pendant. The staff acknowledged the calls timely and cleared most of them within the 10 minutes. Based on the evidence in this case the allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of report emailed to the administrator.the state’s words, verbatim · CDSS document, Dec 15, 2022 · control 29-AS-20210804135150

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) De Leon conducted an on site 1 year infection control annual visit to the facility above on 07/27/2022 at 3:30 PM . LPA met with Jodi Beltrama Administrator and explained the purpose of the visit. Administrator took LPA on a physical plant tour of the facility. The facility has submitted a mitigation plan to the department. The facility has an entry point at the front door where everyone entering completes sign-in, symptom questionnaire and temperature screening. All staff, residents returning from an outing, and visitors wanting to come into the facility are required to sign in. All documentation is kept in a binder. The entry station has hand sanitizer along with a thermometer. The facility has a large activity room that is used for television, activities and exercise, all areas are spaced to accommodate as much space as possible for social distancing. All equipment and PPE supplies are kept in the RA office and stored under the stair case, all accessible to staff. Medications are kept in a locked medication room. The kitchen area has a dining area to accommodate distancing between residents when eating meals . The staff screen residents for symptoms and temperature 1x a day and documentation is kept in a binder. Increased monitoring is conducted if any change of condition is noted or any residents showing any signs, symptoms or have a temperature. Signs are posted on the hallway walls through out the facility regarding Covid-19 symptoms to report to staff, coughing and sneezing etiquette, hand hygiene, mask wearing and social distancing. All required postings are hung in common areas of the facility. Staff makes sure residents have a mask when leaving the facility on outings into the community. All staff wear face coverings in the facility and when on outings with residents. Facility has several areas for visiting inside, outside and in rooms. Continued 809C The facility also offers virtual and telephone communications to all residents in care. Staff, residents and visitors are informed of the facilities infection control policies. New residents and staff will be tested and negative results received before working or residing in the facility. The facility has procedures and plans for screening, isolation, testing, when to call 911 and notifying all responsible parties and agencies when needed. Emergency Disaster plan has all agencies with telephone numbers listed. Administrator is in charge of infection control and provides training and education to staff, residents and visitors. Administrator is in charge of staffing and works on any issues or additional coverage. If any suspected or confirmed cases of Covid-19 are found in the facility staff will be assigned to only work with those quarantined/isolated individuals. Staff will use full PPE with N95 masks and face shields when dealing with any pending or confirmed cases of Covid-19. Facility is able to dedicate a single room for resident so isolation can be arranged when and if needed. Residents rooms all have own restroom for resident use. The facility has 3 public restrooms, hand hygiene signs are posted with supplies of soap and paper towels. Precautionary droplet signs will be posted on any room with quarantine or isolated individuals. PPE supplies will be located right outside those rooms when required. Facility has a 30 day supply of PPE on hand. Trash bins have tight fitting lids. Facility has plans for delivering medications and meals to any quarantined/isolation room. The facility has proper cleaning and disinfectant sprays. Facility Administrator has a plan in place for when and whom to notify in an outbreak or other emergencies. Administrator will keep a line list of all vaccinated and tested staff/residents in care with dates/results. Facility has conducted training on infection prevention, symptoms, transmission and PPE use. Facility has non-punitive sick leave polices for staff. Sick staff are requested to stay home and not report to work if ill. Activities have been modified to individuals or small groups with social distancing. Furniture has been moved around to accommodate social distancing between staff and residents as much as it can be. Elevators have signs for social distancing. Continued 809-C Residents medication is delivered in 30 day supplies to the facility. The facility ensures proper cleaning is done on frequently touched surfaces and between any individuals sharing of space or items. Sinks were well stocked with soap and paper towels. Staff files are locked in HR office and resident records are kept locked in RA office . Facility does realize guidance changes and the most up to date guidance from CCL-PINS, CDC, CDPH, and local health departments should be followed to remain in compliance. The most stringent orders should be followed. The facility has a large outside courtyard with shade for residents use. No deficiencies observed during the visit and all infection control protocols are implemented and followed. Exit interview completed and copy of report emailed to Administrator.the state’s words, verbatim · CDSS document, Jul 27, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) De Leon conducted an on site 1 year infection control annual visit to the facility above on 07/29/2021 at 10:00 AM . LPA met with Jodi Beltrama Administrator and explained the purpose of the visit. Administrator took LPA on a physical plant tour of the facility. The facility has submitted a mitigation plan to the department. The facility has an entry point at the front door where everyone entering completes sign-in, symptom questionnaire and temperature screening. All staff, residents returning from an outing, and visitors wanting to come into the facility are required to sign in. All documentation is kept in a binder. The entry station has hand sanitizer along with a thermometer. The facility has a large activity room that is used for Television, activities and exercise, all areas are spaced to accommodate as much space as possible for social distancing. All equipment and PPE supplies are kept in the RA office and stored under the stair case, all accessible to staff. Medications are kept in a locked medication room. The kitchen area has a dining area to accommodate distancing between residents when eating meals . The staff screen residents for symptoms and temperature 1x a day and documentation is kept in a binder. Increased monitoring is conducted if any change of condition is noted or any residents showing any signs, symptoms or have a temperature. Signs are posted on the hallway walls through out the facility regarding Covid-19 symptoms to report to staff, coughing and sneezing etiquette, hand hygiene, mask wearing and social distancing. All required postings are hung in common areas of the facility. Most residents in the facility were wearing masks in the common area. Staff makes sure residents have a mask when leaving the facility on outings into the community. All staff wear face coverings in the facility and when on outings with residents. Facility has several areas for visiting inside, outside and in rooms. Continued 809C The facility also offers virtual and telephone communications to all residents in care. Staff, residents and visitors are informed of the facilities infection control policies. New residents and staff will be tested and negative results received before working or residing in the facility. The facility has procedures and plans for screening, isolation, testing, when to call 911 and notifying all responsible parties and agencies when needed. Emergency Disaster plan has all agencies with telephone numbers listed. Administrator is in charge of infection control and provides training and education to staff, residents and visitors. Administrator is in charge of staffing and works on any issues or additional coverage. If any suspected or confirmed cases of Covid-19 are found in the facility staff will be assigned to only work with those quarantined/isolated individuals and will not work with negative individuals until cleared by Health Department to do so. Staff will use full PPE with N95 masks and face shields when dealing with any pending or confirmed cases of Covid-19. Facility is able to dedicate a single room for resident so isolation can be arranged when and if needed. Residents rooms all have own restroom for resident use. The facility has 3 public restrooms, hand hygiene signs are posted with supplies of soap and paper towels. Precautionary droplet signs will be posted on any room with quarantine or isolated individuals. PPE supplies will be located right outside those rooms when required. Facility has a 30 day supply of PPE on hand. Trash bins outside and in the kitchen area have tight fitting lids. Facility has plans for delivering medications and meals to any quarantined/isolation room. The facility has proper cleaning and disinfectant sprays. The facility has not been fitted tested for N95 masks and LPA explained in an outbreak the facility would need to be wearing N95 and CAL OSHA requires fit testing of those masks. LPA's highly recommended Administrator look into testing for the N95 masks before an outbreak. Facility Administrator has a plan in place for when and whom to notify in an outbreak or other emergencies. Administrator will keep a line list of all vaccinated and tested staff/residents in care with dates/results. Facility has conducted training on infection prevention, symptoms, transmission and PPE use. Facility has non-punitive sick leave polices for staff. Sick staff are requested to stay home and not report to work if ill. Activities have been modified to individuals or small groups with social distancing. Furniture has been moved around to accommodate social distancing between staff and residents as much as it can be. Continued 809-C Residents medication is delivered in 30 day supplies to the facility. The facility ensures proper cleaning is done on frequently touched surfaces and between any individuals sharing of space or items. Sinks were well stocked with soap and paper towels. Staff files are locked in HR office and resident records are kept locked in RA office . Facility does realize guidance changes and the most up to date guidance from CCL-PINS, CDC, CDPH, and local health departments should be followed to remain in compliance. The most stringent orders should be followed to remain in compliance. No deficiencies observed during the visit and all infection control protocols are implemented and followed. Exit interview completed and copy of report emailed to Administrator.the state’s words, verbatim · CDSS document, Jul 29, 2021

Allegation investigated: Staff did not prevent a resident from wandering while in care Staff did not properly report an incident regarding a resident to CCL

Licensing Program Analyst (LPA) De Leon conducted a 10-day complaint visit to the facility above at 1:00pm on 07/07/2021. LPA met with Jodi Beltrama Administrator and explained the purpose of the visit. LPA conducted interviews with staff and witnesses. LPA requested the following documentation: LIC 602 Physicians report for Resident 1 (R1), Pre-Appraisal for R1, Care Conference dates with family of R1, Incident report for the date of the incident, staff notes on room 120, and R1's profile emergency contacts numbers. All records requested were provided to LPA at the visit. LPA reviewed records given. Continued 9099-C Substantiated On the allegation: Staff did not prevent a resident from wandering while in care. LPA interviewed and collected documentation which revealed staff failed to keep Resident (R1) from leaving the facility unassisted. LIC 602 physicians report was marked R1 was unable to leave the facility unassisted. According to Witness 1's (W1's) interview R1 had a family visit with her family and dog, the family left the visit shortly before dinner time on 06/25/2021. R1 did not sign out and wandered outside the facility undetected for around 30 minutes before staff realized she was not at dinner and began to search facility for R1. Facility staff notified Arroyo Grande Police Department and family. Staff started to search outside of the community and staff was able to locate R1 in the surrounding neighborhood. Staff was able to redirect R1 back to the community. Facility and family set up a care conference for the next day and R1 was taken home by family and eventually relocated to another facility that could met R1's changing needs. Therefore, the allegation is deemed Substantiated at this time. On the allegation: Staff did not properly report an incident regarding a resident to CCL. Based on documentation and interviews the facility staff failed to report the incident to Community Care Licensing (CCL) on R1's wondering without supervision on 05/25/2021. Therefore, the allegation is deemed Substantiated at this time. Exit interview conducted, deficiencies cited, copy of report and appeal rights emailed to Administrator.the state’s words, verbatim · CDSS document, Jul 7, 2021 · control 29-AS-20210629114805

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jul 9, 2021

Basic Services (f)Basic services shall at a minimum include:(1)Care and supervision as defined ... This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above, as R1 wandered from the facility without supervision which poses an immediate safety risk to resident in care.the state’s words, verbatim · CDSS document, Jul 7, 2021

Plan of correction: Administrator agreed to set a system in place that identifies residents whom can not leave the facility unassisted and provide training to staff on those residents. Provide proof to CCL.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Jul 7, 2021

Reporting Requirements...(D) Any incident which threatens the welfare, safety or health of any resident ... or unexplained absence of any resident. This requirement was not met as evidenced by: Based on record review, the Licensee did not comply with section cited above, Staff failed to report R1's incident to CCL which poses a potential safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 7, 2021

Plan of correction: Administrator did an incident report immediately for R1's elopement on 05/25/2021 and provided copy to LPA on visit. Administrator will submit all incident reports in the future to CCL.