567609954-5-24-2023-29-AS-KBUY-CSD2E9-20230531171935

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 567609954
Report Date: 05/24/2023
Date Signed: 05/24/2023 06:29:27 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/17/2021 and conducted by Evaluator Rachael De Leon

COMPLAINT CONTROL NUMBER: 29-AS-20211217142605

FACILITY NAME:	ARTESIAN OF OJAI, THE		FACILITY NUMBER:	567609954
ADMINISTRATOR:	MICHAEL O'NEILL		FACILITY TYPE:	740
ADDRESS:	203 E EL ROBLAR DRIVE		TELEPHONE:	(805) 798-9305
CITY:	OJAI	STATE: CA	ZIP CODE:	93023
CAPACITY:	72	CENSUS: 46	DATE:	05/24/2023
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Mike O'Neill, Administrator		TIME COMPLETED:	06:40 PM

ALLEGATION(S):

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Staff did not address a resident's change in medical condition resulting in hospitalization.
Staff did not provide medical information to resident's responsible party in a timely manner.
Staff did not seek medical attention in a timely manner.

INVESTIGATION FINDINGS:

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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 Mike O’Neill and explained the purpose of the visit.

LPA Dulek conducted the initial 10-day complaint visit on 12/20/2021 from 12:19 PM – 2:27 PM, interviewed staff at 12:36PM, toured the facility with Administrator at 12:54PM, reviewed files at 1:12PM, and gathered copies of pertinent documents. LPA Ascencio interviewed staff on 05/05/2022 at 2:50 PM. LPA De Leon interviewed witnesses on 05/02/2023 at 3:30 PM, 05/19/2023 at 1:07 PM, and 05/23/2023 at 12:18 PM. LPA De Leon requested additional documents on 05/18/2023, 05/22/2023 and 05/23/2023. LPA reviewed complaint, interviews and records on 05/18-05/24/2023.

On the allegation: Staff did not address a resident's change in medical condition resulting in hospitalization. LPA reviewed facility staff notes which revealed Resident 1 (R1) was isolated at the facility from 12/04/2021-12/13/2021, on 12/07/2021 R1 was very anxious, R1 told staff that R1 couldn't breath and was coughing notified LVN PRN cough syrup and Lorazepam given to R1,

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

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 29-AS-20211217142605

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ARTESIAN OF OJAI, THE	FACILITY NUMBER: 567609954
	VISIT DATE: 05/24/2023

NARRATIVE

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on 12/10/2021 R1 spent first few hours of this shift, calling for “help”, every 15-30mins R1 would relax some when staff would talk with R1 from R1’s door or go in to check on R1 but would start back up again, on 12/11/2021 R1 has been yelling "help" several times during shift, staff move R1 from bed to wheel chair and wheel chair to recliner R1 was saying R1 was unable to breathe staff offered water and staff tell R1 to slow down take breathes R1 calmed down and fell asleep, later on 12/11/2021 notes state R1 had a rough day, R1 wanted help what seemed to be every 15 minutes R1 was pretty consistently yelling from R1’s room call "911" saying R1 couldn’t breathe staff cut R1’s legs staff took R1’s oxygen level and it was 99 staff double checked R1’s oxygen it was working R1 did not seem to be in distress Med-tech (MT) was notified and assisted R1, later on 12/11/2021 notes state after lunch R1 yelled for “help 911” R1 asked for MT when talking R1 stated R1 needed 911 when asked what was wrong R1 stated her stomach was hurting staff asked where it hurt and what other symptoms R1 had R1 said only that it was hurting R1 said the food caused the upset stomach, later that evening on 12/11/2021 at around 930 R1 started yelling for help that R1 could not breathe you could hear a lot of secretion in R1’s chest staff calmed R1 down and asked LVN for PRN’s have medications, cough syrup with lorazepam (liquid) R1 did fall asleep for a few hours R1 throughout this shift was yelling for 911 to be called, complaining of being mistreated, calling for R1’s children etc. this went on till after 9:00 PM when R1 finally fell asleep, on 12/12/2021 R1 has been yelling "help", "call 911" staff assured R1 and R1 slept for a few hours but was up and awake this would go on throughout the night, later on 12/12/2021 another noted stated R1 was very needy today R1 was throwing tantrums and wanting to go to the hospital R1’s Tylenol was given at 12:45 for pain R1 had been transferred from the reclining to wheelchair and in bed vice versa throughout the morning, and another note on 12/12/2021 stating R1 had a difficult time today yelling continuously for 911 or needing and wanting Staff offered solutions and options which at times were met with confusing or incoherent verbiage at one point R1 expressed to a staff member that R1 wished R1 would die which was immediately conveyed to MT who in turn called staff nurse R1 ate very little dinner at the time of this observation being noted R1 had been sleeping quietly R1 was checked taken to bathroom and encouraged to drink water, on 12/13/2021 it is noted R1 had been screaming "help me" for no reason, staff pushed fluids, R1 had cream of wheat for breakfast dentures are too loose for R1’s mouth R1 calmed down around 1PM R1 looked exhausted and remained in R1’s chair, on 12/14/2021 R1 was yelling at beginning of shift and at end of shift notified LVN and LVN gave R1 Lorazepam, cough syrup and Tylenol.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 29-AS-20211217142605

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ARTESIAN OF OJAI, THE	FACILITY NUMBER: 567609954
	VISIT DATE: 05/24/2023

NARRATIVE

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The notes continue later that same day just before 4pm R1 had complaints of pain "all over" R1 said pain was at a level 9 R1’s family was asking for something for R1 also notified LVN PRN Hydrocodone given R1 took albuterol late this afternoon because during the time scheduled R1 was either in restroom or with R1’s family visiting R1 chose to drink a little ensure before supper at supper R1’s BP was 107/80 LVN notified and advised staff to hold R1’s Metaprolol, later on 12/14/2021 another note indicating R1 has been yelling consistently, seems anxious/agitated and has also been coughing notified LVN, R1 was given lorazepam and cough syrup, on 12/15/2021 staff noted R1 woke up around 1215am yelling for help but didn’t say what R1 needed help with called LVN R1 told LVN R1 had pain staff gave R1 a PRN after 5 minutes R1 started yelling for LVN again staff called LVN again and R1 calmed down went to sleep, another note that day states R1 has been super duper out of it today MT and LVN notified LVN spent some time with R1 and gave R1 albuterol, which seemed to calm R1 down for a while R1 has been constantly crying for help and saying "something isn't right" R1 is unable to tell staff what R1 needs help with and has not been making any sense, on 12/16/2021 it is noted R1 at 1040 started yelling complained of pain staff notified LVN Morphine was given then at 1150 R1 started yelling again for help and R1’s family members notified LVN Lorazepam was given then at 3am R1 started yelling again staff stayed in R1’s room to try and figure out what was wrong, also to try and push R1 into bed because R1 was leaning on edge R1 told me not to touch R1 and started to yell to just throw R1 out by 4am notified LVN and R1 told LVN R1’s stomach and back hurt Norco was given R1 had finally fallen back asleep at 5am, called Doctor office to get R1 in to see the doctor. Resident has not been self since Monday. Staff at the doctors office let LVN know there was not any appointments available, Doctor office told LVN to call back tomorrow at 8am to see if they could get R1 in tomorrow, then a note was put in on 12/22/2021 out of sequence stating LVN called Dr office to get R1 in to see the doctor as R1 has not been self since Monday the doctor’s office let LVN know there was not any appointments available and told LVN to call back tomorrow at 8am to see if the doctor could get R1 in tomorrow, then notes go back to 12/16/2021 R1 slept all morning, R1 started to get agitated and in pain around 1:15 MT was informed and a nurse came from an agency to assess R1, then later on 12/16/2021 another note was put in indicating home health nurse came to visit informed staff that R1’s vitals were very low nurse called 911 when EMT's arrived they stated that R1 vitals were within normal limits LVN asked paramedics to please take R1 to the hospital for evaluation that is what R1’s family wants LVN tried to explained that LVN tried to get R1 into the doctors earlier but the doctor didn't have any appointments available so EMT's took R1 to the doctor, on 12/17/2021 note indicated checked with R1’s family on how R1 was doing family informed staff that R1 has pneumonia and would be in the hospital for a little longer then R1’s family would be moving R1 to a board n care. The notes from 12/18/2021 – 12/21/2021 stated R1 was still in Hospital, then a final note was written indicating on 12/21/2021 informed by R1’s family R1 passed away in the hospital.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 29-AS-20211217142605

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ARTESIAN OF OJAI, THE	FACILITY NUMBER: 567609954
	VISIT DATE: 05/24/2023

NARRATIVE

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W3’s interview revealed on 12/15/21, R1’s family member called Home Health Agency to state concerns about a recent COVID outbreak at the facility, family said that facility lifted the quarantine over the weekend, Family members went to visit R1 on the weekend and R1 reported that R1 has been having breathing issues. W3 stated on 12/16/21, the family asked for Home Health to send a nurse to the facility to check in on R1. The nurse went to the facility and found R1 seated and slumped over, the nurse tested R1’s oxygen, it was in the 70's, nurse asked staff members why R1 was slumped over and staff told nurse R1 was fine when they checked R1 earlier. R1’s blood pressure was very low and R1 lips were dry and cracked, R1 was not talking but then R1 would repeatedly suddenly wake up and begin yelling, 'I'm gonna die!' and then fall back unconscious. A three-way call took place with family, the nurse from home health and the MT at The Artesian. Home Health Nurse advised staff at the facility that R1 needed assistance from a nurse and the MT said LVN is on lunch, and staff said I don't know what you want me to do so the Nurse called 911 and R1 was transported to the hospital. Based on the evidence this allegation is deemed Substantiated at this time.

On the allegation: Staff did not provide medical information to resident's responsible party in a timely manner. LPA De Leon’s interview with W3 revealed when R1’s family contacted the facility during the quarantined they were told R1 was fine and asymptomatic but once able to visit the facility R1 complained of breathing issues which sparked the family to call Home Health and have a nurse check on R1. According to staff notes R1 was complaining of breathing issues and pain during this time. W3 stated that when Home Health called to check on R1 they were told that R1 was fine. R1 was transported to the hospital after the Home Health Nurse came to visit and called 911 on 12/16/2021. R1 passed away in the hospital on 12/21/2021. R1’s family was not notified that R1 was having any medical issues while on quarantine. Based on the evidence this allegation is deemed Substantiated at this time.

On the allegation: Staff did not seek medical attention in a timely manner. LPA De Leon reviewed staff notes indicating R1 was complaining of pain and breathing issues for 8 or more days medications and PRN’s were given but R1 was never seen by a doctor until 911 was called and R1 was transported to the hospital. R1 was not taken to the hospital until R1’s family sent a Home Health Agency Nurse to check on R1. The Home Health Nurse called 911 and had R1 transported to the hospital. R1 passed away in the hospital on 12/21/2021 and the family notified the facility. Based on the evidence this allegation is deemed Substantiated at this time.

Exit interview conducted, deficencies cited, copy of report and appeal rights printed for Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 29-AS-20211217142605

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ARTESIAN OF OJAI, THE	FACILITY NUMBER: 567609954
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/24/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/26/2023 Section Cited CCR 87466	1 2 3 4 5 6 7	The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to review and train staff on policy and procedures for observation and reporting of a residents change in condition. Provide proof of training to CCL.
	8 9 10 11 12 13 14	Based on interviews and records review the Licensee did not comply with the regulations above, staff notes revealed unmet needs for R1 that were not brought the attention of R1 physician or RP which possess an immediate health, safety and personal rights risk to residents in care.	8 9 10 11 12 13 14
Type A 05/26/2023 Section Cited CCR 87465(g)	1 2 3 4 5 6 7	(g)The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to review/train all staff in observation of resident, emergency, change in conditions, and when to call 911 or seek medical attention timely. Provide proof of training to CCL.
	8 9 10 11 12 13 14	Based on interviews and record review the licensee did not comply with the regulation above the facility did not call 911 when R1 was displaying change in conditions and asked for 911 to be called for breathing issues and pain which possess an immediate health, safety and personal rights risk to residents in care.	8 9 10 11 12 13 14

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: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

LIC9099 (FAS) - (06/04)

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