Other·January 6, 2022

A State Citation Class A was written. Regulation: F 835 - §483.70 Administration. A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Title 22 72305 (a)(b)(1)(3) Physician Services - Medical Director (a) The facility shall have a medical director who shall be responsible for standards, coordination, surveillance and planning for improvement of medical care in the facility. (b) The medical director shall: (1) Act as a liaison between administration and attending physicians. (3) Act as a consultant to the director of nursing service in matters relating to patient care services. Title 22 72327(a) Nursing Service - Director of Nursing Service (a)The director of nursing service shall be a registered nurse and shall be employed eight hours a day, on the day shift five days a week. Title 22 72351(a)(b) Dietetic Service - Staff (a) A dietitian shall be employed on a full-time, part-time or consulting basis. Part-time or consultant services shall be provided on the premises at appropriate times on a regularly scheduled basis. A written record of the frequency, nature and duration (b) If a dietitian is not employed full-time, a full-time person who is a graduate of a state approved course that provides 90 or more hours of classroom instruction in food supervision shall be employed to be responsible for the operation of the food service. The dietetic supervisor may also cook, provided sufficient time is allowed for managerial responsibilities. Title 22 72385(a)(b)(1)(2)(3) Activity Program - Staff (a) Activity program personnel with appropriate training and experience shall be available to meet the needs and interests of patients. (b) An activity program leader shall be designated by and be responsible to the administration. An activity program leader shall meet one of the following requirements: (1) Have two years of experience in a social or recreational program within the past five years, one year of which was full-time in a patient activities program in a health care setting. (2) Be an occupational therapist, art therapist, music therapist, dance therapist, recreation therapist or occupational therapy assistant. (3) Have satisfactorily completed at least 36 hours of training in a course designed specifically for this position and approved by the Department and shall receive regular consultation from an occupational therapist, occupational therapy assistant or recreation therapist who has at least one year of experience in a health care setting. Title 22 72437(b) Social Work Service Unit - Staff (b) The social work service unit shall be organized, directed and supervised by a social worker, who is responsible for supervision of other social work staff, including social work assistants and social work aides. Title 22 72517(a) Staff Development (a) Each facility shall have an ongoing educational program planned and conducted for the development and improvement of necessary skills and knowledge for all facility personnel. Each program shall include, but not be limited to: Title 22 72637(d) General Maintenance (d) Personnel shall be employed to provide preventive maintenance and to carry out the required maintenance program. The facility failed to be administered in an effective manner when qualified management and leadership positions were not filled or provided for by the licensee for Governing Body, Quality, Director of Nursing, Infection Prevention, Food Services, Social Services, Activities and Facility Engineering, and the Director of Staff Development. In addition, the facility did not have a functional quality assurance and performance improvement committee and the medical director was not providing oversight of the facility, nor were they aware of the status of the facility in a COVID outbreak. This failure had the potential for resident harm and possibly death to 19 out of 19 facility residents. On 11/15/21 - 11/23/21, a recertification survey was conducted at the facility. 1. GOVERNING BODY During an interview with Licensed Staff F, on 11/15/21, at 2:30 p.m., she stated she was only in her position as Interim Director of Nursing (DON), for two weeks. She stated she was unable to locate any minutes for the Governing Board. She stated she had never heard of any meeting or projects related to Governing Body. During an interview with Administrative Staff A, in his office, on 11/15/21, at 3:15 p.m., he stated he was unable to locate any Governing Body minutes. He stated he had not attended any meetings or had been requested to submit anything to the Governing Body. He stated the facility did not have a Governing Body. During a phone interview on 11/18/21, at 11:25 a.m., Administrative Staff D stated he was the Vice President of Operations for the facility. He stated he had not heard of a Governing Body and was not involved in anything called a Governing Body. He stated he heard of operational problems with the facility through the nurses and Regional Representatives of the company. Administrative Staff D stated he knew that the Administrator went out on family leave for a couple of months then left the facility, and the Director of Nurses left. He stated there were management vacancies and had hired staff two weeks ago to replace them. He was unable to stated what plan was in place to provide oversight at the facility and provide residents needed services. During a phone interview on 11/18/21, at 3:44 p.m., Medical Director P stated the DON had left the day of or before he started at the facility. He stated the Administrator was on leave and he did not know who was in charge. He stated he never attended any meetings and did not know anything about a Governing Body. 2. Quality Assurance and Performance Improvement (QAPI) During an interview with Licensed Staff F, on 11/15/21, at 2:30 p.m., she stated she was only in her position as Interim Director of Nursing (DON), for two weeks. She stated she was unable to locate any minutes for the Quality Assurance and Performance Improvement (QAPI) Committee. She stated she was unaware of any Performance Improvement Projects the facility had initiated and was working on. During an interview with Administrative Staff A, in his office, on 11/15/21, at 3:15 p.m., he stated he had been in his current position for only a couple of weeks. He stated he was unable to locate any QAPI minutes. He stated the facility had not had any QAPI meetings that he was aware of. During a phone interview on 11/18/21, at 11:25 a.m., Administrative Staff D stated he was the Vice President of Operations for the facility. He stated he had not heard of a QAPI Committee for the facility. He stated he heard of operational problems with the facility through the nurses and Regional Representatives of the company. Administrative Staff D stated he knew that the Administrator went out on family leave for a couple of months then left, and the Director of Nurses left. He stated there were management vacancies and had hired staff two weeks ago to replace them. He was unable to stated what plan was in place to provide oversight at the facility and provide residents needed services. During a phone interview on 11/18/21, at 3:44 p.m., Medical Director P stated the DON had left the day of or before he started at the facility. He stated the Administrator was on leave and he did not know who was in charge. He stated he never attended any QAPI meetings. 3. DIRECTOR OF NURSING During an interview with Licensed Staff E and Licensed Staff F, on 11/15/21 at 2:30 p.m., in the Director of Nursing Office, they both stated they had been here for two or three weeks. They both stated they had no Skilled Nursing Experience. They stated the facility did not provide orientation or training and thought they were supposed to fill in for the Director of Nursing (DON) and the Infection Preventionist (IP) positions that were currently unfilled. Licensed Staff E stated she was not sure she could do the job if she did not receive any help. Licensed Staff E and F stated they had not seen a job description for the DON or IP positions. During an interview with Administrative Staff A on 11/15/21, at 4 p.m., in his office, he stated he has been at the facility for three weeks. He stated currently there is no Director of Nursing. He stated there had not been a DON since 4/9/21. During an interview with Licensed Staff F on 11/16/21, at 8:30 a.m., he stated Licensed Staff E was not here. He stated he guessed he was the DON. He stated he did not know what the expectations were. During a phone interview with Administrative Staff D on 11/18/21, at 11:25 a.m., he stated he relied upon nursing to tell him about any issues. He stated he knew about the DON and IP vacancies. During a phone interview on 11/18/21, at 3:44 p.m., Medical Director P stated he started as the Medical Director around 1/2/21 and knew at that time the DON had left the day of or before he arrived. He stated, "There was no DON," and did not know who was in charge. During an interview and record review on 11/19/21, at 10:10 a.m., Administrative Staff C stated he had been in his position for two and a half weeks. He was asked to provide the facility file for Licensed Staff F. He stated he was unable to find any Human Resource files. During an interview and record review on 11/19/21, at 10:50 a.m., Administrative Staff C stated he was able to locate some electronic files that indicate the previous DON had left the facility on 4/7/21. He stated Licensed Staff F started as a Registered Nurse but there was no signed job description for DON. He stated the facility had no documentation of an orientation, competency, background check, or licensed confirmation from the California Board of Registered Nursing that she had a current license to practice nursing in the state of California. He was unable to state the risk to residents if staff were not oriented or competent to do the job they were hired to do. During a phone interview with Administrative Staff D on 11/22/21, at 3:29 p.m., he stated the facility did not have a qualified Director of Nursing Services. During an interview on 11/16/21 at 4:03 p.m., with Responsible Party 330 (RP 330), she stated, Resident 13 had not been having his wounds cared appropriately. She stated when she visited Resident 13, she noticed that the treatment lotions that had been discontinued were left at his bedside. RP 330 stated, she thought it was one particular shift that had not been adhering to the most updated treatment plan. RP 330 stated she did not know who to go to about this since the nursing director had left and the previous administrator had not responded to her calls. During an interview on 11/18/21 at 3:11 p.m. with Licensed Staff O, she stated she inputs assessment information into a Minimum Data Set when there is a change in condition, quarterly and then annually. Licensed Staff O stated she does this work remotely and does not meet with the residents individually. She stated she obtains the assessments signed by nurses or by others competent to complete a component of the assessment. The admission assessment was reviewed for Resident 121 who had been admitted to the facility on 9/2/21. When asked about the nurse who signed the assessment, Licensed Staff O stated she did not know who the nurse was and was not familiar with the name. Licensed Staff O stated Resident 121's admission assessments had been completed on 11/15/21. She stated that the admission assessment was completed late since the assessment should have been completed within seven days of admission. Licensed Staff O stated if the assessments had not been completed correctly, the plan of care would not be accurate and create resident safety issues. Licensed Staff O stated she knew the facility had problems with filling positions and was just trying to help them out part time. She stated she could only fulfill the position remotely since she had other job to do. 4. INFECTION PREVENTION During an interview and observation on 11/15/21 at 9:10 a.m. with Licensed Staff E, in the administrator's office, he continued to pull his mask down below his chin to speak and would keep it down for approximately a minute and then state, he should keep his mask up and would then pull his mask over his nose and chin. Licensed Staff E stated he was not the Infection Preventionist or the Director of Nursing and that both of those roles were currently vacant. Licensed Staff E stated he had not decided if he wanted to take either role but would be helping out during the survey. During an observation on 11/15/21, at 9:15 a.m., Licensed Staff E was observed in the hallway, not wearing his mask over his mouth and nose. During an observation at 12:35 p.m., Licensed Staff E was observed in the Resident Dining Room assisting residents. Licensed Staff E was observed wearing a mask that did not cover his nose and mouth. During an observation and interview on 11/15/21, at 1:15 p.m., Licensed Staff E was observed seated in the nursing station wearing a mask that did not cover his nose and mouth. He stated the facility Policy and Procedure (P&P) for wearing a mask was cover nose and mouth according to Centers for Disease Control (CDC). He stated he was not wearing it properly and the risk to residents was cross contamination and possible infection or death. During an observation on 11/16/21, at 9 a.m., Licensed Staff E was observed at the resident medicine cart across from the nursing station wearing a mask that did not cover his nose and mouth. During an observation on 11/17/21, at 12:15 p.m., during lunch, Licensed Staff E was observed checking resident trays with a mask that did not cover his mouth and nose. During an observation and interview, at 11/16/21, at 3:45 p.m., Licensed Staff E was observed counting the narcotic drawer in the medicine cart outside the nursing station. He stated he was working the evening shift because there was not enough staff. During an interview on 11/15/21, at 2:30 p.m., Licensed Staff E and Licensed Staff F stated they had been at the facility for two weeks and had not receive any orientation to the facility. They stated they were supposed to be filling in for the DON and Infection Preventionist (IP) positions, and they had no experience in Skilled Nursing. They stated they had not been trained or oriented for IP, had no certifications for IP and did not feel competent. During an interview with Administrative Staff A on 11/15/21, at 4 p.m., in his office, he stated he has been at the facility for three weeks. He stated currently there was no Infection Preventionist (IP). He stated the previous IP had quit 11/12/21. He stated Licensed Staff E was supposed to be the IP but needed training and he had not been able to provide it. He stated there was no one available to train him. During an interview with Licensed Staff E on 11/16/21, at 8 a.m., he stated he was the DON for the day since Licensed Staff F was not there. He stated he did not know who would provide the IP oversight for the day if he was the DON for the day. He stated he was unaware the IP had to be available 8 hours a day for IP dedicated work only. During an interview with Licensed Staff E and Licensed Staff F, on 11/17/21, at 4 p.m., they stated they thought they had heard of a potential Covid Exposure to Residents in Room 15 on Monday. They stated they did not know what a Mitigation Plan for Covid was. They stated the exposure may have occurred last week, and residents had not been in any precautions during the time of the possible exposure. They stated the Residents in Room 15 were tested and quarantined in their room. They were not concerned that between last week and today about other residents and staff had been exposed, and no one else had been tested or quarantined in their rooms. During an interview and record review on 11/19/21, at 10:10 a.m., Administrative Staff C stated he had been in his position for two and a half weeks. He was asked to provide the facility file for Licensed Staff E. He stated he was unable to