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Inspection visit

complaint

OCEANSIDE ELDERLY CARE HOME 452License 3746038423 citations on this visit
3 citations recorded

Inspector’s narrative

What the inspector wrote

[CONTINUED FROM LIC 9099] At the time of the complaint allegation, R1 was being followed by a visiting nurse practitioner (NP), who operated as an extension of R1’s primary care physician (PCP), to help address R1’s health issues as they developed. Care records and interviews aligned to show that R1 was memory-impaired, wheelchair-bound, took blood-thinner medication, had very fragile skin, had a history of being prone to bruising and skin tears, wore incontinence briefs, and required staff assistance with mobility, transferring, and incontinence care, among other tasks. According to interviews of Licensees/managers, facility caregivers usually checked residents’ briefs at least once every two (2) hours, changing them if they are wet or soiled. However, one of these managers also acknowledged that the overnight staff (who are alone on duty) were also allowed to themselves nap in between their incontinence check rounds, and that there was typically a period from around “10:30 PM or 11:00 PM” to around “4:00 AM to 5:00 AM” daily when the overnight staff were allowed to sleep. Caregiver interviews varied slightly, but they generally corroborated that there was usually a window of between four (4) to six hours (6) during the overnight shift when R1 was not being visually checked on. According to caregiver interviews: Around 7:00 AM on 07-26-2024, Caregiver Staff #1 (S1), who had just started their work shift, went to R1’s bedroom and first observed that R1 had a raised bump on their forehead and a skin tear on their neck that had bled. While R1 was still in bed, there was some dried blood on their pillow, and several other pillows were on the floor beside their bed. Caregiver Staff #2 (S2) was the lone staff on duty during the preceding overnight shift. Per interview of S2: They had last checked on R1 around 5:00 AM, finding nothing out of the ordinary. They denied R1 having fallen out of bed. They did not have a clear explanation for R1’s injuries. They mentioned R1 briefly screamed when S1 was in the room alone with R1. LPA asked, but S2 did not believe that S1 harmed R1 during the encounter. Per interview of S1: They denied harming S1 or causing any skin injuries during the incident. S1 had asked S2 what had occurred prior to their own arrival at work, but S2 did not have an explanation for R1’s injuries. S1 photographed R1’s injuries and bedroom, then notified R1’s responsible person. LPA tried to interview R1 about the incident, but they had no memory of it. S1 and S2 said: R1 was also unable to state to them what had happened to them. [CONTINUED ON LIC 9099-C, 2 of 3] [CONTINUED FROM LIC 9099-C, 1 of 3] LPA obtained multiple photographs (some of which were time and date-stamped), coming from multiple sources, which together showed: R1 initially had an abrasion and slightly raised bump on the middle of their forehead that was 1.5 inches wide by 1 inch long. This raised bump on R1’s forehead later lowered, and a bruise about 4 inches wide by 5 inches long formed in its place. R1 also had a bruise and a skin tear on their neck (that bled), and the blood had dried by the time it was discovered. There was also a small amount of dried blood on one pillow on R1’s bed. R1’s other four pillows were on the floor beside their bed. There was also a prominent wet stain on their bedsheet (resembling urine) about 4 feet wide by 1 foot long, where R1’s back would have been. Interviews of S1 and S2 had showed that R1 had been wearing their incontinence briefs at the time they were discovered in this condition, despite their bed being visibly wet. Then around 08-06-2024, a skin tear developed on top of a pre-existing hematoma on R1’s lower right leg. (Per the National Institutes of Health, a hematoma is a pool of mostly clotted blood that forms in a body space, such as under the skin.) CCLD obtained before and after photographs of the hematoma intact, and the subsequent skin tear, showing that at one point, the open area of skin was around 2 inches long by 1.5 inches wide. LPA interviewed pertinent caregivers, which showed that while some were aware of this injury, all interviewed were also uncertain as to how it was caused. Although R1’s 07-26-2024 and 08-06-2024 injuries were timely reported to R1’s responsible person, staff and outside source interviews clearly showed that Licensee did not notify either R1’s physician or R1’s nurse practitioner about the above incidents/injuries involving R1. By the time the complaint was filed and CCLD began investigating, R1’s forehead abrasion had healed, their forehead bruise had faded, their neck skin tear had healed, and their lower right leg skin tear had scabbed over and healed, yet 2 of 2 facility Licensees/managers and 2 of 5 caregivers (who directly cared for R1) interviewed were still unaware that these injuries to R1 had earlier occurred. There was also no written documentation of these specific injuries to R1 in the facility’s records, as was required. LPA reviewed the CCLD San Diego Regional Office’s files, finding that Licensee did not submit written incident reports regarding the above injuries to R1 (which was required to be done within seven days of incident occurrence). Incident reports were also required to be sent to R1's responsible person, and interviews showed that was also not done. [CONTINUED ON LIC 9099-C, 3 of 3] [CONTINUED FROM LIC 9099-C, 2 of 3] Interviews of Licensees/managers, caregivers, and outside sources also confirmed: After an involuntary facility transfer (which CCLD cited during a separate complaint investigation), Licensee placed R1 into a certain bedroom at Oceanside Elderly Care Home 452 during late July 2024. However, around 08-02-2024, Licensee again moved R1, this time to a different bedroom within the facility, without providing advance written notice to R1’s responsible person or securing their consent. R1 was not cognitively capable of consenting to this room change. Per interviews of Licensees/managers and corroborated by LPA observation: R1 (who was an existing resident) was moved to a different room to make way for a brand-new resident who was moving in, and who themselves desired the bedroom that R1 was already occupying. Both bedrooms were private (non-shared) and there was no emergency which necessitated R1’s room change/transfer. Based on records and interviews, a preponderance of evidence exists to show that Licensee did not meet requirements regarding observation of a resident, the Licensee did not meet reporting requirements, and that Licensee did not meet personal rights requirements related to a resident’s room change. These three (3) allegations were therefore Substantiated. Deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D pages). Plans of Correction were jointly developed with the Licensee. An exit interview was conducted with Dr. Rahman, to whom a copy of this report, the LIC 9099-D pages, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided. [CONTINUED FROM LIC 9099] Per review of CCLD’s Guardian and Licensing Information System (LIS) databases, during the time frame of the complaint allegation, both S4 and S5, as well as all other current facility staff, were each fingerprinted and possessed active background clearances to work. Interviews of Licensees/managers and facility staff reiterated the same. Based on record review and interviews, the allegation that Licensee’s staff did not have current background / criminal-record clearances is Unfounded, meaning it was false, could not have happened, and/or is without a reasonable basis. The Department has therefore dismissed the allegation, and no deficiency was issued for it. An exit interview was conducted with Dr. Rahman, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Citations

15 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87468.1(a)(12)Type B

    87468.1 Personal Rights of Residents in All Facilities: “(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (12)…to keep and use their own personal possessions, including their toilet articles…” This requirement was not met, as evidenced by: Based on interviews, Licensee did not uphold the right of 2 of 6 residents (R2 and R5) to keep and use their own personal possessions, including their toilet articles. This posed a potential personal rights risk to persons in care.

  • 87101(c)(3)Type B

    87101 Definitions: “(c)(3) ‘Care and Supervision’ shall include, but not be limited to, any one or more of the following activities provided by a person or facility to meet the needs of the residents: (A) Assistance in dressing, grooming, bathing and other personal hygiene…” This requirement was not met, as evidenced by: Based on interviews, Licensee did not meet the grooming/hygiene needs of 1 of 6 residents (R1). This posed a potential health and personal rights risk to persons in care.

  • 87307(a)(3)Type B

    87307 Personal Accommodations and Services: “(a) The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident.” This requirement was not met, as evidenced by: Based on interviews, Licensee did not ensure that 1 of 6 residents (R1) had supplies necessary for personal care and maintenance of adequate hygiene practice readily available to them. This posed a potential health and personal rights risks to persons in care.

  • 87412(f)Type B

    87412 Personnel Records: “(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours.” This requirement was not met, as evidenced by: Based on LPA observation and staff interviews, for 9 of 9 staff (S1 through S9), Licensee did not ensure that their personnel records were available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. This posed a potential safety risk to persons in care.

  • 87456(a)(2)Type B

    87456 Evaluation of Suitability for Admission: “(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall…: (2) Perform a pre-admission appraisal.” This requirement was not met, as evidenced by: Based on records review and manager interview, for 1 of 5 residents (R4), Licensee did not have on file a completed LIC603 Pre-Placement Appraisal (or equivalent pre-admission appraisal document) to evidence that they performed a pre-admission appraisal to evaluate his/her suitability, prior to accepting the resident for care. This posed a potential health, safety, and personal rights risk to persons in care.

  • 87458(a)Type B

    87458 Medical Assessment: “(a) Prior to a person’s acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use form LIC602…to obtain the medical assessment.” This requirement was not met, as evidenced by: Based on records review and manager interview, for 1 of 5 residents (R4), prior to the person’s acceptance as a resident, Licensee did not obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. This posed a potential health, safety, and personal rights risk to persons in care.

  • 87458(b)Type B

    87458 Medical Assessment: “(b) The medical assessment shall include, but not be limited to: …results of an examination for communicable tuberculosis…” This requirement was not met, as evidenced by: Based on records review and manager interview, for 3 of 5 residents (R2, R3, and R4), Licensee did not ensure that the resident had a medical assessment that also included the results of a complete examination for communicable tuberculosis. This posed a potential health risk to persons in care.

  • 87467(a)Type B

    87467 Resident Participation in Decisionmaking: “(a) Prior to, or within two weeks of the resident’s admission, the licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, and any other appropriate parties, to prepare a written record of care the resident will receive in the facility, and the resident’s preferences regarding the services provided at the facility.” This requirement was not met, as evidenced by: Based on records reviewed and interviews, for 4 of 5 residents (R1, R2, R4, and R5), Licensee did not have on file a completed LIC625 Appraisal/Needs and Services Plan (or equivalent “written record of care the resident will receive”), to include the resident’s preferences regarding the services provided at the facility. This posed a potential health and personal rights risks to persons in care.

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  • 87705(c)(5)Type B

    87705 Care of Persons with Dementia: “(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: “(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually…” This requirement was not met, as evidenced by: Based on records and manager interview, for 1 of 5 residents (R5), who was diagnosed with dementia, Licensee did not ensure that they had a medical assessment and care reappraisal done at least annually. This posed a potential health risk to persons in care.

  • 87705(j)Type B

    87705 Care of Persons with Dementia: “(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.” This requirement was not met, as evidenced by: Based on LPA observation and staff interviews, Licensee did not continuously maintain an auditory device or other staff alert feature to monitor exits. This posed a potential safety risk to 6 of 6 residents (R1 through R6) in care.

  • 87211(a)(1)(D)Type B

    87211 Reporting Requirements: "(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) 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...(D) Any incident which threatens the welfare, safety or health of any resident." This requirement was not met, as evidenced by: Based on records and interviews, 1 of 5 residents (R1) had incidents which threatened their welfare/health, and Licensee did not submit a written report of the incidents to the licensing agency and the person responsible for the resident within seven days of incident occurrence. This posed a potential health risk to persons in care.

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  • 87466Type B

    87466 Observation of the Resident: “The licensee shall ensure that residents are regularly observed for changes in physical…functioning... When changes such as…deterioration of…a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident’s physician and the resident’s responsible person, if any.” This requirement was not met, as evidenced by: Based on records and interviews, 1 of 5 residents (R1) had a deterioration of a physical health condition which staff observed, but Licensee did not ensure that this change was documented and brought to the attention of the resident’s physician (or their staff) and responsible person. This posed a potential health risk to persons in care.

  • 87468.2(a)(16)Type B

    87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: “(a)…residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (16) To written notice of any room changes at least 30 days in advance unless a room change is agreed to by the resident, required to fill a vacant bed, or necessary due to an emergency.” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not ensure that 1 of 5 residents (R1) received written notice of room change at least 30 days in advance. The room change was not done with resident consent, or to fill a vacant bed, or due to an emergency. This posed a potential personal rights risk to persons in care.

  • 87652(b)(3)Type A

    87625 Managed Incontinence: “(b)…the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.” This requirement was not met, as evidenced by: Based on interviews and photographic evidence: For 1 of 5 residents (R1), who was incontinent, Licensee did not ensure that they were kept clean and dry. This posed an immediate health and personal rights risk to persons in care.

  • 87303(b)(2)Type B

    87303 Maintenance and Operation: “(b) A comfortable temperature for residents shall be maintained at all times. (2) The facility shall cool rooms to a comfortable range, between 78 degrees F…and 85 degrees F…” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not at all times maintain a comfortable temperature for residents, by cooling rooms to a comfortable range between 78 degrees F and 85 degrees F. This posed a potential health and personal rights risk to 5 of 5 residents (R1 through R5) in care.

FAQ · About this visit

Common questions about this visit

What happened during the October 11, 2024 inspection of OCEANSIDE ELDERLY CARE HOME 452?

This was a complaint inspection of OCEANSIDE ELDERLY CARE HOME 452 on October 11, 2024. 3 citations were issued: 3 Type B.

Were any citations issued to OCEANSIDE ELDERLY CARE HOME 452 on October 11, 2024?

Yes, 3 citations were issued (0 Type A, 3 Type B). The first citation was for: "87468.1 Personal Rights of Residents in All Facilities: “(a) Residents in all residential care facilities for the elderl..."

What type of inspection was this?

This was a complaint inspection. Complaint inspections are triggered when someone reports a concern about the facility to CCLD.

SourceView on CCLDView original report

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