Follow-up on corrections·December 28, 2021

Licensing Program Analysts (LPAs) Salia Walker and Elsie Campos conducted an unannounced Case Management- Deficiencies inspection visit at the facility today due to deficiencies observed during the subsequent visit of complaint control #29-AS-20211129153412. At 2:11 p.m., the LPAs observed a key inserted on the facility’s front entrance doorknob on the outside. At 2:13 p.m., the LPAs advised staff #1 (S1) the facility entrance key is not to be on the front doorknob for the safety of the residents and staff. S1 immediately removed the facility entrance and acknowledged understanding. At 2:49 p.m., the LPAs advised Administrator Rebeka Durgaryan of the facility key being inserted in the front entrance doorknob. The Administrator acknowledged, and explained the reason for the key being placed on the doorknob is per resident request. The LPAs explained to the Administrator and residents the severity of leaving the facility key on the outside front entrance doorknob, as any one can enter the facility, which poses immediate risk to the residents in care. At 2:13 p.m., Resident #1 (R1) opened the front door providing access for the LPAs to enter. At 2:13 p.m., S1 rushed to the LPAs stating that S1 was in the middle of changing another resident. During the physical plant tour at 2:15 p.m., the LPAs also observed a mop bucket with water in the common bathroom. S1 stated she was also in the middle of mopping the common bathroom floor, but stepped away to tend to other resident needs. At 2:49 p.m., the Administrator confirmed R1 has Dementia. The LPAs advised the Administrator that upon arrival R1 opened the door for the LPAs as S1 was unable to open the door timely due to being occupied assisting another resident. The administrator acknowledged understanding. Civil Penalties are being assessed today for a Repeat Violation on section 87411(a), as the facility had been cited for the same citation section 87411(a) on 09/14/2021. Continue on LIC809C.. At 2:26 p.m., the LPAs observed two (2) cabinet doors unlocked containing accessible medications such as over the counter ointments ‘Calmoseptine’, and ‘Triple Antibiotic Ointment.’ At 2:30 p.m., the LPAs observed accessible medication in two (2) out two (2) facility refrigerators that were not properly stored inside a medication lock box. Medications accessible included; ‘risperidone,’ ‘Dulcolax,’ ‘Lorazepam,’ and ‘Sodium Chloride Inhalation Solution.’ The LPAs advised S1 and the Administrator all medications shall be stored inaccessible to residents with Dementia. The administrator stated the facility only has one medication lock box, but would immediately obtain a second medication lock box to secure the remaining resident medications that did not fit in the first lock box. At 2:27 p.m., the LPAs observed the facility’s sharp items lock box was unlocked and accessible to residents in care. The LPAs advised S1 that knives, and sharps shall be locked and secured at all time inaccessible to residents in care. At 2:49 p.m., the LPAs advised the Administrator that the LPAs observed culinary knives, and other sharps were accessible in the kitchen, which poses an immediate health and safety risk to residents in care. The LPA advised the Administrator that all sharps including knives must remain locked and secured at all times while caring for persons with dementia. The Administrator acknowledged understanding. At 2:31 p.m., During the physical plant tour the LPAs observed one (1) out of two (2) facility kitchen refrigerators contained expired condiments. S1 removed the expired condiments and discarded them into the trash bin. At 3:04 p.m., the LPAs conducted a record review. Record review revealed, Resident #1 (R1) did not have a completed facility file, including a completed medical assessment, emergency identification, signed personal rights, resident appraisal, Appraisal needs and Services plan, centrally stored medication and destruction record, Consent to Medical Examination. The only records R1 had in file was hospital records. Record review also revealed the following, Resident #2 (R2) did not have a completed facility file, including a medical assessment, emergency identification, signed personal rights, resident appraisal, Appraisal needs and Services plan, centrally stored medication and destruction record. Record review revealed that Resident #3 (R3) did not have a completed facility file, including an admissions agreement, a completed medical assessment, emergency identification, signed personal rights, resident appraisal, Appraisal needs and Services plan, centrally stored medication and destruction record, Consent to Medical Examination. At 2:49 p.m., the LPAs advised the Administrator that all resident file shall be completed and contain the required forms filled out completely. The Administrator stated that she mailed the form for the residents to the responsible parties, but the responsible parties did not return the completed forms. Continue on LIC809C.. At 3:20 p.m., during the record review the LPAs inquired about the Hospice Care Plans for R2, and R3. The Administrator stated that the ‘ABC Hospice’ did not provide the Care plan for R2. The Administrator also stated that ‘ABC Hospice’ retrieved the Hospice Care plan for R3. The LPAs advised the Administrator the required documentation for two (2) out of five (5) resident files did not contain the Hospice care plan. The LPAs advised the administrator that all records shall be maintained in the facility for the duration of three years. Pursuant to Title 22 of the California Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted, today's reports and appeal rights were reviewed and issued. Civil penalties issued.