Non-compliance follow-up·October 8, 2024

On 10/08/24, Licensing Program Analyst (LPA) Kimberly Viarella and Licensing Program Manager (LPM) Stephen Richardson, made an unannounced visit to this facility as a follow-up to a non-compliance meeting that was conducted on 10/23/23. LPA Viarella identified herself upon arrival, stated the purpose of the visit, and asked to meet with the Designated Facility Administrator. LPA/LPM met with the Designee, Tina Riley, LVN, and Senior Executive Director, Tristin Benjamin.  The four conducted a walkthrough of the facility. The group toured all interior areas including assisted living, memory care, 4 medication rooms, the dining room and the kitchen.  The group also visited a model room and recently vacated room and observed that both contained pull cords by the bedsides as well in the bathrooms. During the walkthrough, the LPA/LPM observed 5 residents participating in a staff led painting activity in one of the assisted living lounges and 8 residents in memory care playing Family Feud led by a staff member in their activity room.  Toward the end of the tour the LPA/LPM observed 26 residents in the assisted living dining room having lunch with 2 servers in attendance.  Throughout the tour, LPA/LPM observed staff providing care to the residents in different areas of the facility along with housekeeping  servicing rooms in both memory care and assisted living. At the conclusion of the walkthrough, the four met to review the concerns that were discussed on 10/23/23.  At this meeting the Designee and the Executive Director provided the following updates. Since that meeting the facility has done the following: The facility now has a Resident Care Coordinator and Wellness nurse in place. In addition, all nurses and medication technicians have had additional training on passing techniques, policies and systems.  Eskaton Central Support and Senior RCFE quality and compliance nurse conducted additional audits, record review, training and competency checks. Trainings were updated regarding insulin and diabetes management. The facility has ceased to accept residents who cannot manage their own blood sugar monitoring and insulin administration. Front desk coverage was extended to 10:00 PM 7 days a week. The front door lock was replaced with a keyed system to ensure only authorized staff can lock and unlock doors. The facility has also implemented Care Coordination Meetings (CCMs) with an emphasis on those residents who have experienced recent changes in condition or care needs and were intended to be proactive  and preventative. The facility also launched its own Eskaton Academy in June 2023 which trains all new care staff  and many existing staff.  The Designee, Tina Riley, highlighted that they were developing an effective method for tracking all necessary training which would include the hours of each training, the credentials of the trainer as well as the name of the person a trainee shadowed.  A new Electronic Medication Administration Record system (EMAR) was launched on 03/01/24. The LPA/LPM were also told in this meeting that the "Great Catch" pilot program was launched in November and has been successful in encouraging staff to communicate things across departments in order to improve resident care and safety. The meeting ended with Community Care Licensing stating that they were looking forward to being a resource and assisting the facility as they work toward achieving and maintaining compliance with their new staff.  Quarterly visits will continue until further notice from the regional office. According to the California Code of Regulations, Title 22, no deficiencies were observed or cited during today's visit. A copy of this report was provided and an exit interview was conducted.