Routine inspection·August 9, 2022

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required – 1 yr. Infection Control inspection to this facility. LPA were greeted by staff and then staff Janine Sorensen arrived later. Licensee, Ami Kumar was not able to come to the facility, but was available by phone and gave authorization to staff to sign the report. There were 6 residents in care present at the facility. LPA arrived at the facility and did not had their temperature checked and logged into a sign-in sheet. LPA/staff discussed the importance of screening visitors. LPA observed that facility have posters on the front door indicating visitors about updated visitor's policy to protect residents in care. Once inside the facility, LPA observed that staff were wearing masks during this visit. LPA/staff conducted a walk-through of the facility and observed Covid-19 posters that included hand washing signs. Hand sanitizer were observed in the common area of the facility. Facility bathroom are kept stocked with hand hygiene and paper products. Commonly touched surfaces are disinfected at least three times a day. Each resident has their own room in case that needs to isolate and the facility is able to serve meals and deliver medications. Facility staff have been trained on PPE protocols and N-95 fit tested. Staff and residents are being monitored daily and results are documented. Facility maintains a 30 day supply of medication. Per Licensee, facility has a 100% vaccination rate and received boosters for staff and residents. Residents do not typically wear a mask while in the facility, but they do wear masks when in the community. Residents receive indoor visitation with their families and facility is able to perform antigen tests to visitors as well as screening, documenting for symptoms and tracking purposes. Facility has submitted their Covid Mitigation Plan and approved on 3/29/21. Facility also has submitted their Infection Control Plan to CCL for review. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including masks, face shields and hand sanitizer. PPE supplies are accessible for staff. Facility agreed to provide updates of the following by 8/16/22: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), Liability insurance and Emergency Disaster Plan (LIC610E). Continues on LIC809C... Continued from LIC809... During today's visit, LPA also followed up on three self-incident reports submitted to Community Care Licensing. Per incident report, on 7/15/22 resident (R1) was in living room and got up on their own without a walker, staff was in kitchen motion sensor went off. Staff went to attend R1 and remind them that they need to use the walker, R1 became anxious, agitated and hit staff when staff stepped back and R1 lost their balance when swinging and fell backwards. 911 was called and R1 was sent to Kaiser for further evaluation. Also, resident's responsible party and case manager were notified about the incident. R1 was sent back to the home after all testing ordered were all fine. Doctor discontinued some medications, prescribed new medication Zyprexa and scheduled some follow up appointments to discuss medication changes. Per second incident report submitted, R1 on the same date woke up in the middle of the night and was having delusions, staff contacted Janine Sorensen to discuss about PRN medication use. However, R1 was still up all night confused, tried to get up and fell back to bed. Staff contacted 911 as instructed per Janine and R1 was transported and admitted to the Kaiser Hospital for broken left shoulder and broken left wrist. R1 was scheduled for surgery on 7/22/22 and R1 will be discharged to go to Rehabilitation. LPA was provided with R1's discharge documents dated 7/15/22 instructing to discontinue new medication prescribed Zypresa until discussing further with their doctor. R1 is currently under care of Apple Valley Post Acute and will be discharged back to the home on 8/12/22. On 8/9/22 CCL received another self-incident report. Per incident report, on 8/5/22 motion sensor went off at 5am and staff found R2 on the floor, R2 seemed confused and staff called hospice who advised to get them back to bed, give them 1/2 tab of morphine and a nurse will be sent to evaluate. Upon nurse arrival, R2 was assessed and was sent to the ER for possible hip fracture. R2's responsible party were notified. R2 was evaluated and diagnosed with a broken hip, R2's family decided not to have surgery and R2 was sent back to the facility on hospice. LPA was provided with information that R2's care plan was updated. Hospice nurse placed a wedge between resident's legs and trained staff how to reposition resident. No deficiencies cited during this inspection.