Routine inspection (multi-day)·May 8, 2024

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management visit to continue the annual inspection from 5/2/2024. LPA Rai met with Lead Staff (LS) Mary Ann Villanueva. LPA Rai observed 2 staff and 6 residents at the facility. At this time, the facility has 2 hospice residents. During today's visit, LPA Rai followed up with 2 staff files. On 5/2/2024, LPA Rai reviewed 1 staff file for S1 where first aid training was expired. During today's visit, LPA Rai observed S1's first aid training was completed on 5/3/2024. On 5/2/2024, LPA Rai reviewed staff file for S2 where S2's Tuberculosis (TB) test was not included in the health screening and a separate TB test results were not found in the file. During today's visit, LPA Rai observed S2's TB test result in the file with a note stating the new records were from another facility the Licensee currently manages along with this current facility. During today's visit, LPA Rai reviewed 2 resident files who are not on hospice services. LPA Rai observed R1-R2''s file did not contain the Appraisal/Needs and Services Plan. R2's file did not contain a signed order for half-side rails attached to R2's bed and LS clarified R2 is not on hospice services. R2's file did contain an Admission Agreement but it's not for this current facility. LPA Rai observed the water temperature in the bathroom sinks ranged from 118.4 degrees Fahrenheit - 119.3 degrees Fahrenheit. The water temperature in the kitchen sink was 118.9 degrees Fahrenheit. Facility smoke detectors and carbon monoxide detectors were in working condition. The last disaster drill was conducted on 4/5/2024. LPA Rai observe the thermometer in the freezer was measured at 0 degrees Fahrenheit and the thermometer in the fridge was measured at 40 degrees Fahrenheit. Continuation on LIC 809-C, Page 1 of 3. Page 2 of 3. During today's visit, LPA Rai reviewed 2 resident medications and central stored medication records for resident R1 and R2. For R1, 1 out of 3 medications were not given as prescribed to the resident. Medication #3 was prescribed as 1 tablet 3 times a day as well as PRN as needed. The medication bottle was started on 4/29/2024 and the medication in the bottle when opened were 60 tablets. LPA Rai and LS counted the tablets in medication #3's bottle and observed 27 tablets. LPA Rai observed PRN sheet noted PRN medication was administered on 3/22/2024, prior to this current medication bottle was started. LPA Rai observed there were 3 tablets were missing from bottle. LS stated resident does ask for PRN in the evenings for pain, however, LS stated she did not write the information in the PRN log. For R2, resident's file does not contain a document where R2's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication. In addition, 4 out of 4 medications were not given as prescribed to the resident. Medication #4 was prescribed as 1 tablet a day and the medication bottle was started on 4/21/2024. It was logged on the Centrally Stored Medication Record (CSMR) as 94 tablets in the bottle when started. LS stated R2's medications came from another facility so LS counted all the medications when R2 was admitted and recorded in on R2' Centrally Stored Medication log. LPA Rai and LS counted the tablets in Medication #4 bottle and observed 71 tablets. LPA Rai observed there were 5 tablets tablets missing from the bottle. LS looked at medication cabinet and discovered R2's medication bottles that LS stores medication when R2 refused medication. LS provided LPA Rai a medication bottle which was not the original container for medication #4 and contained two different medications. LPA Rai observed 5 tablets matched the color and size of medication #4 and two tablets that were a different size and color. LPA Rai advised LS to keep medications in the prescribed bottles and not to mix medications into a different medication bottle. LS agreed and understood. Medication #5 was prescribed as 1 tablet given on Monday, Wednesday and Friday and the medication bottle was started on 4/10/2024. It was logged on the CSMR as 100 tablets in the bottle when started. LPA Rai and LS counted the tablets in Medication #5 bottle and observed 89 tablets and there should be 61 tablets in the bottle, LPA Rai observed there were 28 extra tablets in the bottle. LS stated R2 will refused the medication. LS provided the Medication Administration Record, and LPA Rai observed the medication was initialed by LS stating the medication was given to resident as prescribed but there were still 28 tablets extra in the bottle. Page 3 of 3. Medication #6 was prescribed as 1.5 tablets at bedtime. It was logged on the CSMR as 87 tablets in the bottle when started on 4/9/2024. LPA Rai and LS counted the tablets in Medication #6 bottle and observed 44.5 tablet and there should be 43.5 tablets, LPA Rai observed there was 1 extra tablet in the bottle. LS stated R2 will refused the medication. LS provided the Medication Administration Record, and LPA Rai observed the medication was initialed by LS stating the medication was given to resident as prescribed. LS stated R2 will drop the medication on the floor when the room is dark and LS has had to replace the medication and throw the dropped tablet in the trash. LS stated she did not log on the destruction log. LS stated she might have started the medication on 4/10/2024 not as logged on CSMR as 4/9/2024. LPA Rai advised LS to correctly document the CSMR log as accurately as possible. Medication #7 was prescribed as 1 tablets daily and the medication bottle was started on 4/9/2024. It was logged on the CSMR as 24 tablets in the bottle when started. LPA Rai and LS counted the tablets in Medication #7 bottle and observed 24 tablets and there should be 26 tablets, LPA Rai observed there were 2 missing tablets in the bottle. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D. 87411 Personnel Requirements - General is being cited during today's visit. LPA Rai would like to clarify the facility personnel being in sufficient in numbers is not the concern, however the facility personnel's actions and documentation are observed to be not competent to provide the services necessary to meet the resident's needs. Lead Staff attempted to reach Licensee Leilani Cortes over the phone and Licensee was not available and was not present at the other two facilities managed by Licensee. Exit interview was conducted with Lead Staff, Mary Ann Villanueva. A copy of this report was provided to Lead Caregiver, Mary Ann Villanueva. Appeal Rights were provided. .