Follow-up on corrections·August 27, 2021

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced in order to investigate a complaint (#18-AS-20210825090919). During LPA Colvin's review of records at the facility, LPA Colvin observed some additional deficiencies. LPA Colvin met with Administrator/Licensee Verly Frias and advised Verly of the purpose of the visit. Below are the issues that were discussed: Current Staff Training - LPA Colvin reviewed facility files and observed that prior resident (R1) was bedridden and had a G-Tube (gastronomy tube). LPA Colvin reviewed staff files and observed that facility staff (S1 & S2) were not trained in care of bedridden residents or in providing care for G-Tubes. Deficiencies cited . Care of Bedridden Residents - LPA Colvin observed that the facility does not have fire clearance for bedridden residents, yet R1 was admitted and retained at the facility while bedridden for almost 1 year. Licensee informed LPA Colvin that R1 was on Hospice, which permits them to retain R1. LPA Colvin informed Licensee that Title 22 Regulation 87633(l) states that while the facility may retain a bedridden person on Hospice, they must still meet all the requirements of regulation section 87606. The facility has not met the requirements of 87606 as observed in this report. Deficiency cited . A violation of a facility's fire clearance results in an immediate $500 civil penalty, which will be issued at the end of the exit interview. Additionally, the facility does not have a Plan of Operation on file which includes care of bedridden residents. Deficiency cited. Hospice Records - LPA Colvin observed that the facility did not have any documentation relating to the Hospice care of R1. S1 stated that the family removed the hospice file without their permission. LPA Colvin noted that there should be a copy of the Care Plan in R1's file, which there was not. Deficiency cited. Unscrupulous Training Certificates - During LPA Colvin's review of staff files, LPA Colvin observed that the CPR certifications for all staff were expired. LPA Colvin inquired about current certification for staff, which S1 was able to provide to LPA Colvin after bringing out a separate large envelope. At this time, LPA Colvin observed several stacks of training certificates which looked identical from those found in staff files, though these certificates were blank where the staff name would be listed. LPA Colvin looked through these certificates and observed that they were identical to those in staff files, right down to listing all of the same training, same date, and same instructor. LPA Colvin questioned Administrator/Licensee Verly Frias regarding the certificates, and showed him the ones in staff files. Administrator/Licensee Verly Frias denied knowledge of these and could not account for who's signature the trainer on the certificates was, nor did he have their contact information. LPA Colvin reminded Verly that he is both the Licensee and Administrator for the facility, so he should have knowledge regarding staff training records. No explanation was provided during LPA Colvin's inspection regarding these blank records. Due to deficiencies cited today as well as concern with blank staff records, LPA Colvin invited Administrator/Licensee Verly Frias to an Informal Meeting via Zoom to discuss facility's plan for compliance. Informal Meeting will take place Tuesday, August 31, 2021 at 2:00pm. Due to observations made by LPA Colvn, the facility was cited deficiencies and civil penalties in the amount of $500 were issued. LPA Colvin conducted an exit interview with Administrator/Licensee Verly Frias, where a copy of this report, LIC809Ds, LIC421IM, and appeal rights were provided.