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13 | On 3/29/2022, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS- 20220105090920 . LPA Han met with the resident service director, Ronnie McCarthy and explained the purpose of the visit. In addition, the Vice President Of Operations, Nicole Mashburn and Regional support, Kelly Hatter joined over the phone
Regarding to allegation of- insufficient staffing to meet residents' needs, the reporting party stated that there were several shifts during the night shift at 10pm- 6am that was only 1 staff worked the entire facility and 1 staff worked at the other facility that is located across the street. During the investigation, LPA Han interviewed the administrator, staff, residents and reviewed the staff time-sheet records.
The administrator denied the above allegation and stated that each facility should have 1 medication technician and 1-2 caregivers during the night shift at 10pm- 6am. However, LPA reviewed the time-sheet records with the administrator and it revealed 1 day in December 2021, and 2 days in January 2022 that only 1 staff worked at each facility. The administrator explained that there were dietary and housekeeping staff worked on those days as a caregivers, however, the administrator was not able to provide any documents to show that the dietary and housekeeping staff worked on those days and the administrator was not able provide any training records indicating that dietary and housekeeping staff were properly training to provide direct care and supervision. |
| Substantiated | Estimated Days of Completion: |
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NARRATIVE |
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32 | In addition, LPA Han interviewed staff #1(S1) who stated that there were many days especially on Fridays, Saturdays, and Sundays, there was only 1 staff worked at each facility during the night shifts and when that staff was asked to assist at the facility across the street, that would leave one facility unattended.
Furthermore, LPA interviewed resident #1 (R1), resident #2 (R2) and resident #3 (R3) regarding the staffing situation for the facility and all three of them stated that there is staffing shortage at the facility especially during the night shifts and in result of that, they got their medications late all the time and 1 resident stated that staff did not provide incontinent care at night.
Based on interviews, observations and record review during the investigation, this allegation is substantiated.
Regarding to allegation of- facility did not notify residents authorized representative of COVID-19 exposures, the facility had positive COVID-19 cases in December, 2021 but the facility did not provide any type of notification to anyone.
During the investigation, LPA interviewed the administrator who was not aware that the facility had positive COVID-19 cases in December 2021 but the administrator stated that the facility had its first case of positive COVID-19 in January 2022 and the facility has provided both verbal and written notices to residents and responsible parties. However, the administrator was not able to provide a copy of the written notification that was given to the residents and the responsible parties. LPA interviewed Staff #2 (S2), staff #3 (S3) and Staff #4 (S4) and all of them stated that the facility has had positive COVID-19 cases since December 2021. In addition, LPA interviewed R1 and R2 and both of them stated that they were not inform of any possible COVID-19 cases at the facility.
Based on interviews, observations and record review during the investigation, this allegation is substantiated.
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13 | On 3/29/2022, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS- 20220105090920 . LPA Han met with the resident service director, Ronnie McCarthy and explained the purpose of the visit. In addition, the Vice President Of Operations, Nicole Mashburn and Regional support, Kelly Hatter joined over the phone
Regarding to allegation of - staff did not prevent the spread of communicable disease, the reporting party stated that resident #5 (R5) returned to the facility with 3 different type of antibiotics for a suspected infection that required isolation. However, R5 was not placed on isolation until a few days later.
During the investigation, LPA interviewed S2 and Staff #3 (S3) and both of them stated that the facility was not aware that R5's infection that required isolation until a few days later. According to S2, when the facility was made aware that R5 required isolation, R5 was placed on isolation right away.
Based on interviews and observations during the investigation, this allegation is unsubstantiated.
This report is reviewed and discussed with the resident service director. A copy is provided. |
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
04/01/2022
Section Cited
CCR
87411(a) | 1
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7 | 87411 Personnel Requirements - General(a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.....This requirement is not met as evidence by: | 1
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7 | The facility needs to develop a staffing schedule to ensure sufficient staffing is available to provide care during all shifts. In addition, the facility needs to develop a plan and/or a protocol to cover for sick-calls including but not limiting to cover for last minute sick calls. |
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14 | According to the facility's staff time-sheet records, there was one day in December 2021 and 2 days in January 2022 indicating only one staff who worked on the night shift for the entire facility and when this staff was asked to assist with the sister facility that is located across the street, the staff would leave his/her assigned facility unattened and assist with the sister facility which posed an immediate health and safety risks to residents in care. | 8
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14 | The administrator and/or the designee will provide education to facility on the plans above. The administrator will provide a copy of the above plans and a copy of the education sign-in record of the participants to CCL by the plan of correction due date 4/1/2022. |
Type A
04/01/2022
Section Cited
CCR
87465(c)(2) | 1
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7 | 87465 Incidental Medical and Dental Care...(c)If the resident's physician has stated in writing that the resident is...(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidence by: the facility's electonic medication administration records revealed | 1
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7 | The administrator and/or the resident service director will provide education to all the facility staff who administers medication on medication administration and provide a copy of the sign-in record of the participants to CCL by 4/1/2022. |
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14 | medications were not given within the time prescribed by the physician, medciations were administered but there were notes indicating that medications were not available and according to R2, the medications were given late and sometimes R2 was given the wrong medication which posed an immediate health and safety risks to residents in care. | 8
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14 | The administrator and/or the resident service director will establish a plan to conduct routine medication administration audits to ensure compliance. The administrator will educate facility staff on the audit plan and will submit a copy of the audit plan to CCL. In addition, the administrator will submit a copy of the education sign-in record to CCL by 4/1/2022 |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
04/12/2022
Section Cited
CCR
87468.1(a)(8) | 1
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7 | 87468.1 Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:8) To have their representatives regularly informed by the licensee of activities related to care or services,..This requirement is not met as evidenced by: | 1
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7 | The administrator will review this regulation and submit a signed written statement of acknowledgment to CCL by the plan of correction due date 4/12/2022. |
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14 | The facility failed to provide any notices to residents and respoonsbility parties when the facility was experiencing positive COVID-19 cases which posed a potential health and safety risks to resident in care. | 8
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Type B
04/12/2022
Section Cited
CCR
87468.1(a) | 1
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7 | 87468.1 Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations,.... | 1
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7 | The administrator and/or the designee will educate facility staff on rendering services to residents during all shifts. The administrator will establish a documentation tool (similar to the am and pm shift documentation tool) for the night shift facility staff to document when the care is rendered. |
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14 | This requirement is not met as evidenced by: during the investigation, R3 stated that there were many nights incontinent care was not provided and the facility was not able to provide documentation that care was provided during the night shift which posed a potential health and safety risks to residents in care. | 8
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14 | The administrator will provide a copy of the above documentation tool and a copy of the sign-in education record to CCL by 4/12/2022. |