Routine inspection·October 24, 2024

Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator Emily Pascua and explained the purpose of the visit. Upon arrival, LPAs Moleski and Williams observed a resident (R1) sitting in a chair with large amounts of dark-colored bruising covering their face. LPAs Moleski and Williams asked Pascua about the cause of these injuries, and she said R1 had fallen on 10/21/24. LPA Moleski reviewed an incident report submitted to the Community Care Licensing Division on that same date. According to the incident report, R1 went to the bathroom around 2:30 p.m. and fell, hitting their head and right forearm. Immediately after the fall, R1 exhibited redness to their left eye and forehead, and had a wound on their upper nose. R1's right forearm had an open wound, a skin tear, and bruising, according to the incident report. The report further stated that first aid was provided to R1, including antibiotic ointment and gauze for R1's wounds, and R1's responsible party was notified. In an interview, Pascua said that 911 was not called. She said that R1's responsible party was texted immediately after the incident and asked whether or not R1 should be sent to the hospital, but R1's responsible party did not respond to her inquiry until the next day. Pascua said that R1's responsible party told her that R1 did not need to be sent to the hospital. 22 CCR Section 87465(g) states that " 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 ." Pascua admitted that 911 should have been called after the incident described above. [continued on 809-C] LPAs Moleski and Williams reviewed three resident files (R1-R3) and two staff files (S1-S2). LPA Moleski observed all residents (R1-R3) did not have needs and services plans on file. LPA Moleski observed that R3 was diagnosed with stage three pressure ulcers on both buttocks while at a skilled nursing facility (SNF) as of 2/4/23, according to admission records from the SNF. R3's LIC 602 dated 2/15/23 indicated that R3 still had at least one stage 3 pressure ulcer on their buttocks. R3's preadmission appraisal, signed by Pascua, the resident, and the resident's responsible party as of 2/21/23, indicated that R3 had two stage three pressure ulcers on both buttocks. R3 signed this facility's admission agreement on that same date, 2/21/23. Pascua confirmed that R3 had never received hospice care while at this facility. Pascua said the wounds have since healed. LPAs Moleski and Williams toured the facility with Pascua and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 73 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 112 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. While touring the facility, LPAs Moleski and Williams and Pascua observed an unlocked bathroom cabinet which contained a disinfectant. In a different bathroom in a resident room, LPAs Moleski and Williams and Pascua observed an unlocked cabinet with a container of powdered cleaner with bleach. Additionally, LPAs Moleski and Williams and Pascua observed multiple medications for R3 left in unlocked drawers and cabinets in that bathroom. The medications included various creams, eyedrops, powders, and lidocaine patches. R3 is not able to store their own medications, according to R3's most recent LIC 602 on file, dated 3/3/23. LPA Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked cabinet for the storage of medication. LPA Moleski observed locked cabinets for the storage of cleaning solutions and knives in the kitchen. LPA Williams interviewed one staff member (S1) and two residents (R1-R2). This facility is hereby cited per 22 CCR Sections 87465(g), 87615(a)(1), 87465(h)(2), and 87309(a), and HSC Section 1569.695(e)(2). An exit interview was held with Pascua. Appeal rights and a copy of this report were left with Pascua.