198603286-10-10-2023-28-AS-RORN-CXRV6L-20231120150942

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 10/10/2023
Date Signed: 10/10/2023 01:37:24 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/25/2020 and conducted by Evaluator Bennette Pena

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200925154403

FACILITY NAME:	PASADENA VILLA SENIOR LIVING		FACILITY NUMBER:	198603286
ADMINISTRATOR:	MURPHY, MICHAEL		FACILITY TYPE:	740
ADDRESS:	1811 N. RAYMOND AVE		TELEPHONE:	(626) 791-6232
CITY:	PASADENA	STATE: CA	ZIP CODE:	91103
CAPACITY:	97	CENSUS: 72	DATE:	10/10/2023
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Alexander Solorio - Assistant Administrator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff not assisting resident with medications.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bennette Pena conducted a subsequent unannounced visit at the facility for the purpose of investigating the above-mentioned allegation. LPA Pena met with Assistant Administrator Alexander Solorio and explained the purpose for the visit.

During the initial visit on 9/29/2020, Licensing Program Analyst (LPA) Renee Arterberry conducted an unannounced 24 Hour Health and Wellness Check telephonically and virtually (via FaceTime) with Alexander Solorio facility administrator and facility nurse Marisol Cruz, employees of the facility. LPA Arterberry interviewed S1-S2, reviewed the facility file for R1, obtained copies of the following documents: Identification Page/Face Sheet, Pre-Appraisal Assessment, Medication Administration Record (MAR), Admission Agreement, Medical Assessment, Unusual Incident Reports (SIR) and hospice documents. LPA Arterberry also toured the physical plant: kitchen, dining room, and medication room.

During the subsequent visit on 2/17/2023, Licensing Program Analyst (LPA) Bennette Pena conducted a tour of the physical plant and obtained copies of the following documents: current resident/staff roster and R1's files such as: Face sheet, Physician's Report, Admission's Agreement, Resident Appraisal, Hospice Health Information, Incident Reports and Medication Administration Records (MARs) for Aug 2020-Oct 2020. LPA also interviewed Resident #2 (R2) - Resident #6 (R6), Staff #1 (S1), Staff #3 (S3), Staff #4 (S4) and telephonically interviewed Staff #2 (S2).

During the 2nd subsequent visit on 3/10/2023, Licensing Program Analyst (LPA) Bennette Pena obtained additional documents for R1 such as: National Rehab Center Discharge Instructions (dated 8/11/2020), Plan of Care (POC) Summaries (dated 9/09/2020, 9/24/2020), Physician’s medication order (dated 10/02/2020) and Huntington Hospital Discharge Instructions (dated 10/02/2020).

During today's visit, LPA Bennette Pena obtained the staff & resident rosters and conducted a facility tour of the common areas. *****CONTINUED ON LIC9099-C*****

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 28-AS-20200925154403

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PASADENA VILLA SENIOR LIVING	FACILITY NUMBER: 198603286
	VISIT DATE: 10/10/2023

NARRATIVE

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The investigation revealed the following:

Regarding allegation: "Staff not assisting resident with medications." It is alleged that the last time the resident received his medication was two days prior to being admitted at the hospital. And the resident alleged that the staff does not check on the resident enough and that he has been in pain for eight days and constipated for three. Based on documents reviewed, R1 was admitted at Huntington Hospital on 9/23/2020 complaining of severe abdominal pain and was diagnosed of pneumonia and renal failure. R1 was assessed by EMS and observed rigidity, pain, distension and tenderness in all four quadrants. On 9/20/2020, R1 complained to staff of having pain related to his catheter and the staff gave R1 medication. Staff indicated that they emptied R1's urine bag but did not document how much nor how the urine looked. LPA reviewed R1's Medication Administration Record (MAR) for Sep. 2020 which indicated that no pain medication was given to R1 except on the evening of 9/20/2020 for moderate to severe pain and in the afternoon on 9/21/2020. On 9/22/2020, the staff indicated that R1's stool was normal and R1 appeared lethargic but noted to have irregular heart rate. However, there was no evidence that the staff re-checked R1 if the pain medication was effective and no evidence that the foley catheter and urine was checked. Reviews of the documents revealed that the facility did not properly monitor the resident who started to deteriorate on 9/20/2020 and did not provide the available medications to R1 to help alleviate his fever on 9/22/2020 and R1's pain. Additionally, based on the records reviewed, the facility did not properly care for R1's foley catheter as there was no documentation that the instruction for catheter irrigation was followed by staff. The facility did not properly care for R1 when the last foley catheter placement was 10 days prior to being admitted to the hospital. Documents showed that this was not performed by the hospice skilled nurse as the last foley catheter change/insertion by hospice was 8/25/2020. Interview with a staff indicated that a NOC shift caregiver pulled out the catheter and pushed it back in while providing care. Other staff interviewed indicated that they were also aware of it. Therefore, there was enough supportive evidence to corroborate the allegation.

Based on LPA’s interviews, and review of documentation regarding R1, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency cited on the attached LIC 9099D.

An exit interview was conducted, and a copy of this report was provided to the Assistant Administrator Alexander Solorio along with the Appeals Rights.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20200925154403

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PASADENA VILLA SENIOR LIVING	FACILITY NUMBER: 198603286
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/10/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/11/2023 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care...(c) ...resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2)..the medication is given according to the physician's directions. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator will submit an effective and written plan to ensure residents receive their medication as prescribed by their Physicians. The written plan will be submitted to CCL/LPA by POC due date.
	8 9 10 11 12 13 14	Based on interviews and review of documentation, R1's Medication Administration Record (MAR) for Sep. 2020, no medication was given to R1 to help alleviate his severe pain and fever except on 9/20/2020 and 9/21/2020 only which posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC9099 (FAS) - (06/04)

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