Cogswell Garden Home

Pre-Admission Appraisal - GeneralPrior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.If a needs assessment has already been completed by a placement agency or consultant, this shall be obtained and included in the facility's appraisal. This requirement was not met as evidenced by:The facility did not implement the IPP and did not complete a pre admission appraisal that contains the required informationwhich poses a potential health and safety risk for clients in care.

General Food Service Requirements(b) The following food service requirements shall apply:Modified diets prescribed by a resident's physician as a medical necessity shall be provided.This requirement was not met as evidenced by: Review of Corrective Action Plan, and interviews conducted the facility did not follow a PKU diet, did not implement IPP and did not review IPP prior to placement for C 1 and C 2 which poses a potential health and safety risk for clients in care.

Pre-Admission Appraisal - GeneralPrior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.If a needs assessment has already been completed by a placement agency or consultant, this shall be obtained and included in the facility's appraisal. This requirement was not met as evidenced by:The facility did not implement the IPP and did not complete a pre admission appraisal that contains the required informationwhich poses a potential health and safety risk for clients in care.

General Food Service Requirements(b) The following food service requirements shall apply:Modified diets prescribed by a resident's physician as a medical necessity shall be provided.This requirement was not met as evidenced by: Review of Corrective Action Plan, and interviews conducted the facility did not follow a PKU diet, did not implement IPP and did not review IPP prior to placement for C 1 and C 2 which poses a potential health and safety risk for clients in care.

Personal Rights of Residents in All FacilitiesResidents in all residential care facilities for the elderly shall have all of the following personal rights:to be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: review of Corrective Action Plan, and interviews conducted the facility did not follow a PKU diet, did not implement IPP and did not review IPP prior to placement for C 1 and C 2 which poses a potential health and safety risk for clients in care.

Based on (interview), the licensee did not comply with the section cited above in 3 out of 3 clients stated there are no activities which poses/posed a potential health, safety or personal rights risk to persons in care.

General Requirements for Allowable Health Conditions. The licensee shall complete and maintain a current, written record of care for each resident that includes, but is not limited to, the following: Documentation from the physician of the following: (A) Stability of the medical condition(s); (B) Medical condition(s) which require incidental medical services; (C) Method of intervention; (D) Resident's ability to perform the procedure; and (E) An appropriately skilled professional shall be identified who will perform the procedure if the resident needs assistance. This requirement is not being met as evidenced by: During the course of this investigation, facility staff were unable to produce records showing that there was a care plan for the R1's pressure wound (right buttock area) and if staff were following the care plan. On 8/15/23, the Current House Manager looked in the file of R1 and was unable to produce a copy of a care plan for R1. This poses a potential health, safety or personal rights risk to persons in care.

Reporting Requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.This requirement is not being met as evidenced by: Investigator / Dennis Sengconducted an interview with the Administrator and the Administrator admitted that facility staff failed to report the hospitalization and pressure injuries involving R1 to CCL. This poses a potential health, safety or personal rights risk to persons in care.

Personnel Requirements - General. All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance... This requirement is not being met as evidenced by: Staff and facility Registered Nurse (RN) / Nelia Aquino stated that there were no formal trainings conducted for Cogswell Garden Home staff to care and treat for the pressure injuries sustained on R1 and any other residents until after the incident involving R1. Staff acknowledged not being aware that facility could not care for residents with stage three or four pressure injuries due to lack of training. This poses a potential health, safety or personal rights risk to persons in care.

Incidental Medical and Dental Care. The licensee shall provide assistance in meeting necessary medical and dental needs.This requirement is not being met as evidenced by: Records from Outreach Home Health (OHH) show that as early as 12/23/20, OHH noted a stage four pressure wound on R1's right buttock area but yet R1 continued to reside at the facility until being hospitalized on 3/3/21. This was likely due to lack of observation, documentation by facility staff and the lack of communication between staff, the treating physician and the Nurse from OHH. Staff acknowledged fault for failing to seek timely medical care for R1. The former House Manager acknowledged of knowing the extent of R1's injury and failed to obtain medical treatment because he forgot. This poses an immediate health, safety or personal rights risk to persons in care.

Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions. This requirement is not being met as evidenced by:On 8/15/23, LPA reviewed medications/Medication Administration Record (MAR) for Resident 4 (R4) and discovered that the Thick-It Powder (PRN) for R4 was missing at the facility. According to the Current House Manager, staff are administering Resident 5's (R5's) Thick-It Powder to R4 because R4's Thick-It Powder "ran out". This poses an immediate health, safety or personal rights risk to persons in care.

Resident Records. Each resident’s record shall contain at least the following information:Continuing record of any illness, injury, or medical or dental care, when it impacts the resident's ability to function or needed services. This requirement is not being met as evidenced by: R1 was receiving wound care from OHH once per week. The facility did not maintain adequate records for R1. Client Notes prepared by staff dated 2/24/21, stated that “they told us to reposition him from time to time” but there was no documentation in R1's file regarding repositioning the resident. Staff interviewed stated that R1 was given a bath once every three days and staff only conducted body checks on R1 during bathing. Again, there was no documentation in R1's file regarding staff conducting body checks. Staff interviewed stated that logs were not kept for body checks or repositioning. This poses a potential health, safety or personal rights risk to persons in care.

Allowable Health Conditions and the Use of Home Health Agencies. Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: The licensee provides the supporting care and supervision needed to meet the needs of the resident receiving home health care. This requirement is not being met as evidenced by: R1 was admitted to Los Angeles Community Hospital on 3/3/21 and diagnosed with six pressure injuries in different wound areas, including some that were stage four. Each pressure injury was identified as older and appeared to have developed prior to R1’s admission to LACH, on 3/3/21. Records from Outreach Home Health (OHH) show that as early as December 23, 2020, OHH noted a stage four pressure wound on R1's right buttock area. This poses an immediate health, safety or personal rights risk to persons in care.

Prohibited Health Conditions. Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: Stage 3 and 4 pressure injuries. This requirement is not being met as evidenced by: Records from Outreach Home Health (OHH) show that as early as 12/23/20, OHH noted a stage four pressure wound on R1's right buttock area but yet R1 continued to reside at the facility until being hospitalized on 3/3/21. The former House Manager acknowledged of knowing the extent of R1's injury and failed to obtain medical treatment because he forgot. This poses an immediate health, safety or personal rights risk to persons in care.

Incidental Medical and Dental CareA plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self administered medication as needed. This requirement was not met as evidenced by:Based on documentation and interview licensee failed to provide assistance with self administered medication with Client # 1 missing morning dose of medication Amlodipine Besylate 5 mg which posed an Immediate Health and Safety Risk to resident in care.