Non-compliance follow-up·October 13, 2023

Licensing Program Analysts (LPAs) Cuadra and Rummonds arrived at the facility to conduct an unannounced case management Legal/ Non-compliance inspection and cite deficiencies discovered during a complaint investigation met with Executive Director/acting Administrator Liza Hix. LPA was following up on items that were concerning and ensure compliance with Non-Compliance Conference dated 7/2/21: Medications – Facility had residents with unlocked medications in their possession who were not allowed to store and/or dispense medications according to physician's reports on file. At the time of inspection Medications were stored and locked at all times. During facility tour, LPAs/Executive Director observed staff (S1) crushing medications for residents in care. LPAs were informed that there are physician's crush orders on file to crush medications for some residents (R1, R2, R3, R4, R5 & R6). However, there is no crush order from a physician in R1 & R4's file. Administrator requested LPAs time to locate crush orders and email them to for review. Administrator agreed that failure to provide physician's crush order to CCL will result in a citation. LPAs need to conduct further investigation and review prior to make a final determination. Prohibited Conditions: Facility retained a resident with a prohibited condition. Facility provided resident's care notes to document daily resident's care notes and they are not maintained current month of October 2023. LPAs/Executive Director discussed the importance of documenting resident's care notes timely. Medical Assessments: Facility failed to ensure that resident's medical assessments/physician's report is complete as required. LPA reviewed 6 resident (R1, R2, R3, R4, R5 & R6) medical records including their Physician’s reports (LIC602) had been updated within 12 months as indicated per regulation. Timely Medical Attention: Facility failed to seek timely medical attention. LPA reviewed incident report logs received and residents have been assisted with timely medical attention as indicated per regulation. Continued on LIC809C... Continue from LIC809... Facility Food Services: Facility kitchen area was toured by LPA/Executive Director and LPA found that perishable foods were stored in covered containers, and the refrigerator and freezer were at a temperature within regulation. Resident Records: Facility wasn't able to provide CCLD with pre-appraisals for resident's files that were reviewed. LPA reviewed and learned that residents (R1, R2, R3, R4 and R5) records indicated that residents have been assessed for change of condition within the last 12 months per regulation. Staffing: Facility memory care didn't have adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs. LPA/Executive Director reviewed LIC500 Personnel Summary and staff schedule for the month of October 2023. Facility has in Memory Care currently 4 care staff and 1 med tech, along with dining staff helping with meal service but not care. LPA reviewed staff training records and 2 out of 6 staff (S1 & S2) needs to receive 20 hours annual of additional training including medication training required per regulation. Reporting Requirements: Facility failed to report refusal of medications, 911 calls, suspected abuse, etc. LPA reviewed incident report logs that revealed that facility has been reporting incidents to CCL within regulations. LPAs learned through records review and interviews with Administrator that incident report logs received and found incidents not submitted timely to CCL. Per investigation conducted of complaint #21-AS-20230901102047. Also, incident report, the incident occurred on 9/20/23, but it was received at CCL on 10/4/23 which is not within 7 days of occurrence as indicated per regulation. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal rights given. Exit interview conducted with Executive Director and a copy of this report was given.