342700670-10-27-2020-27-AS-KHOS-BV2PEP-20201104101528

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700670
Report Date: 10/27/2020
Date Signed: 10/27/2020 04:23:40 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/09/2020 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20200309100958

FACILITY NAME:	LATER YEARS SENIOR CARE HOME		FACILITY NUMBER:	342700670
ADMINISTRATOR:	ORNELLAS, MARITES		FACILITY TYPE:	740
ADDRESS:	14 ARARAT CT		TELEPHONE:	(916) 538-6096
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95831
CAPACITY:	6	CENSUS: 5	DATE:	10/27/2020
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Marites Ornellas		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Resident sustained pressure injuries while in care
Staff are mismanaging residents’ medications
Staff did not meet residents’ toileting needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Victoria Brown contacted the facility via telephone to commence an unannounced Tele-visit on 10/27/2020 at 12:30pm due to COVID-19 and pre-cautionary measures. LPA met with Marites Ornellas and discussed the purpose of the call and the elements of this type of visit. This visit is to conclude the complaint investigation and deliver findings.

LPA received and reviewed the following documents for Resident #1 (R1): Admission Agreement, Physician Report, ID and Emergency Information, Centrally Stored Medication Log, and Medication Administration Record (MAR), Appraisal and Needs Service Plan, and Resident Appraisal. LPA received and reviewed medical records dated 2/1/2020 through 4/1/2020 from local hospital for R1. LPA also received and reviewed medical records dated 2/10/2020 through 3/9/2020 from the Home Health Agency for R1.

The allegation regarding “Resident sustained pressure injuries while in care,” LPA observed an admission agreement that indicate R1 was admitted into the home on 2/10/2020.

Unsubstantiated

Estimated Days of Completion: 90+

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020

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

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20200309100958

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: LATER YEARS SENIOR CARE HOME	FACILITY NUMBER: 342700670
	VISIT DATE: 10/27/2020

NARRATIVE

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According to the local hospital medical records, R1 was hospitalized from 2/15/2020 to 2/17/2020 for generalized weakness, confusion, constipation and Urinary Tract Infection (UTI) with an order for Home Health services.

Home Health medical records revealed that on 2/19/2020 during their initial visit, R1 did not have any pressure injuries. During the visit, the home health Registered Nurse (RN) provided instructions to the facility staff on preventive measures such as keeping the resident dry and turn positions every 2 hours.

The facility Care Notes dated 2/18/2020 to 2/23/2020 were reviewed and there weren’t any notations that R1 had any skin changes during this time period. Staff #1 (S1) stated R1 had redness not an open wound and that staff used a butt paste ointment to prevent it from opening. S2 stated there was redness on R1 but there were no sores. The care notes also indicated the staff were turning the resident as instructed by the home health RN.

During a visit on 2/25/2020, the home health RN observed a pressure injury on R1’s sacral area at which time she began applying barrier cream. She stated that within 2 weeks of working with R1 the area was a stage 2.

Local hospital medical records also revealed that on 3/7/2020, R1 was seen at the hospital to ensure the pressure injuries were not infected. The medical records indicated that there were ulcers to R1’s rear-end at a stage 2 with no infection and healing well. The Administrator admitted she saw the “bedsores” after the resident came from the hospital.

The investigation revealed that R1 sustained a pressure injury while in care. However, the Licensee is permitted to retain a resident with a stage one or two pressure injury diagnosed by an appropriately skilled professional.

In this case, the Home Health RN stated during an interview that the staff was following her instructions and the pressure injuries were healing. The hospital medical records revealed that the pressure injuries were healed. The staff documented on care notes that R1 was receiving assistance in repositioning every 2 hours. The licensed skilled professional at the hospital and Home Health RN both concur that the pressure injuries were at a stage 2 and healed.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 27-AS-20200309100958

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: LATER YEARS SENIOR CARE HOME	FACILITY NUMBER: 342700670
	VISIT DATE: 10/27/2020

NARRATIVE

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As a result of the investigation of this allegation, the preponderance of evidence has not been met. Therefore, the allegation is deemed to be UNSUBSTANTIATED.

Regarding the allegation, “Staff are mismanaging residents’ medications”, LPA requested and reviewed medication records for R1.

LPA obtained information through interviews that R1’s eyedrop medication was kept in the drawer near the resident’s bed and not refrigerated. LPA observed that R1 was prescribed an eye drop medication (1 eyedrop in each eye at night). It was documented on the MARs as being administered.

Mayo Clinic recommends storing the unopened bottle in the refrigerator, but an opened bottle may be stored in the refrigerator or at room temperature for up to 6 weeks.

LPA also obtained information through interviews that R1 was sleeping a lot and possibly being given Benadryl. Mayo Clinic defines Benadryl as an antihistamine used to relieve or prevent the symptoms of hay fever and other types of allergies. LPA conducted a medication review and observed that R1 was prescribed several medications that may have a side effect of sleepiness and/or drowsiness.

Based on interviews and review of facility records it is unclear whether R1 was sleeping more due to the medications prescribed by a physician or some other means. There was no evidence that suggested R1 was receiving a sleeping aid other than the medication prescribed of which several may have a side effect of sleepiness or drowsiness.

Due to the inconsistencies in the information received through interviews and resident records review, the preponderance of evidence has not been met. Therefore, the allegation is deemed to be UNSUBSTANTIATED.

Regarding the allegation, “Staff did not meet residents’ toileting needs”, LPA reviewed the Local hospital medical records dated 2/1/2020 through 4/1/2020. The medical records revealed that R1 was deemed by Local hospital medical professionals to be incontinent with large amounts of urine.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 27-AS-20200309100958

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: LATER YEARS SENIOR CARE HOME	FACILITY NUMBER: 342700670
	VISIT DATE: 10/27/2020

NARRATIVE

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The Administrator, S1 – S6 all deny that R1 wore 3 diapers at a time. However, they all concur that there was a pad added to the diaper that was provided by the responsible party.

Staff stated that R1 urinated a lot and was hard to coach to the bathroom without responsible parties assistance. Staff also stated that R1 was assisted with incontinence 3-4 times a day, 3 times at night and during the incontinence care, 1 pull-up with a liner inside was used at the suggestion of the responsible party.

The Administrator and the facility RN stated every time R1 was assisted with incontinence, the bedding would also need to be changed and that several pads called “chucks” were used as part of the bedding. Staff also stated that R1 would have episodes of removing a portion of the diaper to urinate outside of it.

LPA observed the facility care notes that indicated R1 was being assisted with incontinence care between every 1-2 ½ hours from 2/18/2020-2/23/2020. Interviews also concluded that resident was assisted to the bathroom or had a diaper change. Interviews and documentation did not reveal that R1 wore 3 diapers and/or pull-ups at a time.

As a result of the investigation of this allegation, the preponderance of evidence has not been met. Therefore, the allegation is deemed to be UNSUBSTANTIATED.

A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, the preponderance of evidence standards has not been met.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. An exit interview was conducted with Marites Ornellas via telephone and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020

LIC9099 (FAS) - (06/04)

Page: 4 of 4