Health inspection·December 18, 2024

Code of Federal Regulations, Title 42, Section 483.70(e) Staff Qualifications. The facility must ensure that – §483.70(e)(2) Professional staff must be licensed, certified, or registered in accordance with applicable State laws. California Code of Regulations, Title 22, Section 72329.1. Nursing Service - Staff. (a) Nursing service personnel shall be employed and on duty in at least the number and with the qualifications determined by the Department to provide the necessary nursing services for patients admitted for care. The staffing requirements required by this section are minimum standards only. Skilled nursing facilities shall employ, and schedule additional staff as needed to ensure quality resident care based on the needs of individual residents and to ensure compliance with all relevant state and federal staffing requirements. The Department may require a facility to provide additional staff as set forth in Section 72501(g). California Code of Regulations, Title 22, Section 72521. Administrative Policies and Procedures. (a) Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. (b) All policies and procedures required by these regulations shall be in writing and shall be carried out as written. They shall be made available upon request to patients or their agents and to employees and the public. Policies procedures shall be reviewed at least annually, revised as needed and approved in writing by the governing body or licensee. (c) Each facility shall establish at least the following: (1) Personnel policies and procedures which shall include: (A) Written job descriptions detailing qualifications, duties and limitations of each classification of employee available to all personnel. (B) Employee orientation to facility, job, patient population, policies, procedures and staff. (C) Staff Development. On 12/3/2024, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a complaint regarding administration and nursing services- staff. As result of the investigation, the CDPH determined that the facility failed to follow its policy and procedure (P&P) titled, “License, Certification, and Registration of Personnel,” and job description (JD) titled, “Director of Staffing Development (DSD- a licensed Registered Nurse [RN] or Licensed Vocational Nurse [LVN- a nurse who provides direct nursing care for people who are sick, injured, convalescent, or disabled] who is approved by the Department),” for the previous DSD/office assistant (OA). The facility failed to: Ensure that the OA did not work without a license to practice nursing from 10/27/2023 to 4/25/2024 while providing care to nine residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, and 9) and working under the title DSD. This failure had the potential to put residents at risk for their safety while under the care of the OA. These violations resulted in Residents 1, 2, 3, 4, 5, 6, 7, 8, and 9 being administered medications or receiving monitoring on 10/28/2023, 10/29/2023, 10/30/2023, 10/31/2023, 11/1/2023, 11/6/2023, 11/8/2023, 11/12/2023, 12/7/2023, 12/30/2023, 3/2/2024, 3/3/2024, 3/14/2024, 3/19/2024, and 3/27/2024 by the OA, who continued to work without a license while in a nursing role as the DSD A review of Resident 3’s Admission Record (AR), indicated the facility admitted Resident 3, an 80-year-old male, on 10/22/2004 and was readmitted on 3/29/2024, with diagnoses that included dementia (progressive states of decline in mental abilities) and protein-calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes body composition and function). A review of Resident 1’s AR, indicated the facility admitted Resident 1, a 64-year-old female, on 9/21/2018 and was readmitted on 4/24/2024, with diagnoses that included dementia and dysphagia (difficulty or discomfort in swallowing). A review of OA’s Director of Staff Development Certificate (DSDC) dated 11/2/2018, indicated the OA completed the course for DSD on 11/2/2018. A review of Resident 9’s AR, indicated the facility admitted Resident 9, a 70-year-old female, on 8/26/2019 and was readmitted on 6/24/2024 with diagnoses that included dementia and chronic obstructive pulmonary disease (COPD- lung disease causing restricted airflow and breathing problems). A review of Resident 8’s AR, indicated the facility admitted Resident 8, a 79-year-old male, on 8/26/2020 and was readmitted on 9/21/2024 with diagnoses that included dementia and major depressive disorder (common and serious illness that negatively affects how one feels, thinks and acts). A review of Resident 4’s AR, the facility admitted Resident 4, a 68-year-old male, on 8/21/2021 and was readmitted on 12/29/2023 with diagnoses that included dementia and unspecified psychosis (severe mental condition in which thoughts and emotions are so affected that contact is lost with external reality). A review of Resident 6’s AR, the facility admitted Resident 6, a 75-year-old male, on 3/8/2022 and was readmitted on 9/15/2023, with diagnoses that included hemiparesis (one-sided muscle weakness caused by a disruption of the brain, spinal cord, or nerves connected to the affected muscles) and hemiplegia (paralysis of one side of the body). A review of Resident 7’s AR, indicated the facility admitted Resident 7, an 87-year-old female, on 10/25/2022 and was readmitted on 11/16/2024 with diagnoses that included Alzheimer’s Disease (a disease characterized by a progressive decline in mental abilities) and unspecified heart failure (disorder characterized by the inability of the heart to pump blood at an adequate volume for organ function). A review of Resident 2’s AR, the facility admitted Resident 2, an 83-year-old female, on 2/17/2023 and was readmitted on 6/30/2024 with diagnoses that included osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D) protein-calorie malnutrition. A review of the decision by the Board of Vocational Nursing and Psychiatric Technicians (BVNPT) and the Department of Consumer Affairs (DCA) for the State of California, dated 9/5/2023, indicated the OA surrendered OA’s LVN license effective 10/27/2023. The decision indicted the OA signed the decision on 9/6/2023. The decision indicated the OA’s LVN license expired on 12/31/2023. A review of Resident 8’s electronic medication administration record (eMAR- record that documents the administration of medication into a resident’s electronic health record) dated 10/20023, indicated the OA indicated on 10/28/2023, 10/29/2023, 10/30/2023, and 10/31/2023, the OA monitored Resident 8 for decreased interest with daily activities of daily living (ADL- the tasks of everyday life fundamental to caring for oneself) leading to self-isolation every shift with use of Lexapro (antidepressant medication) during the day shift and night shift for a total of eight entries. A review the same eMAR, indicated on 10/29/2023, 10/30/2023, and 10/31/2023, the OA monitored Resident 8 for sudden fluctuations of mood, sudden anger, and irritability every shift with use of Depakote (psychotropic- drugs/medications that affect a person’s mental state) during the day shift and night shift, and on 10/28/2023 during the night shift for a total of seven entries. A review of the same eMAR, indicated on 10/28/2023, 10/29/2023, 10/30/2023, and 10/31/2023 the OA monitored Resident 8 for persistent delusion for combat and ready to fight causing verbal aggression, every shift with use of Zyprexa (psychotropic medication) during the day shift and night shift for a total of eight entries. A review of Resident 8’s eMAR dated 11/2023, indicated on 11/1/2023, 11/6/2023, and 11/8/2023, the OA monitored Resident 8 for sudden fluctuations of mood, sudden anger, and irritability every shift with use of Depakote, during the day shift for a total of three entries. A review of the same eMAR, indicated on 11/1/2023, 11/3/2023, 11/6/2023, and 11/8/2023, the OA monitored Resident 8 for persistent delusion for combat and ready to fight causing verbal aggression, every shift with use of Zyprexa, during the day shift for a total of four entries. A review of Resident 9’s eMAR dated 11/2023, indicated on 11/12/2023 at 12:15 pm, the OA signed that Resident 9’s diet was provided as Resident 9’s physician ordered with meals. A review of Resident 3’s eMAR dated 11/2023, indicated on 11/12/023 at 2 pm, the OA gave Resident 3 four ounces (oz- unit of measurement) of high protein nutrition (HPN) for supplement for six months (between meals). A review of Resident 3’s eMAR dated 12/2023, indicated on 12/7/2023 at 2 pm, OA gave Resident 3 four oz of HPN for supplement for six months (between meals). A review of Resident 4’s eMAR dated 12/2023, indicated on 12/30/2023 the OA monitored Resident 4 for delusions that someone was trying to imprison Resident 4 in the facility, every shift with use of Risperidone (psychotropic medication), during the day shift. A review of Resident 5’s AR, indicated the facility admitted Resident 5, a 66-year-old female, on 2/20/2024 and was readmitted on 3/1/2024 with diagnoses that included dementia and unspecified mood disorder (described by marked disruptions in emotions with severe lows and highs). A review of Resident 5’s eMAR dated 3/2024, indicated on 3/2/2024 and 3/3/2024, the OA monitored Resident 5 for persistent delusions that people are secretly planning to do something against Resident 5 causing Resident 5 to falsely accuse everyone, every shift with use of Quetiapine (psychotropic medication), during the day shift for a total of two entries. A review of Resident 6’s electronic treatment administration record (eTAR- a software system that electronically documents and tracks the administration of medical treatments to patients) dated 3/2024, indicated on 3/14/2024, the OA monitored Resident 6’s skin integrity to the right hand daily, every dayshift. A review of Resident 2’s eMAR dated 3/2023, indicated on 3/14/2024 at 9 am, the OA administered Calcium (mineral supplement) 600 mg oral tablet, one tablet by mouth one time a day for supplement. A review of Resident 1’s eMAR dated 3/2024, indicated on 3/19/2024 at 9 am, the OA administered Docusate Sodium (stool softener) tablet, 100 milligrams (mg- unit of measurement), one tablet by mouth two times a day for stool softener. A review of Resident 7’s eTAR dated 3/2024, indicated on 3/27/2024 the OA monitored Resident 7 for discoloration to the left, lower forearm for the follow adverse changes; hematoma (bruise) formation, during the day shift. A review of the facility’s in-service titled, “Human Resources Issues,” dated 4/25/2024, indicated the OA was no longer the DSD. A review of the JD titled, “Medical Records Supervisor/Coordinator,” dated 1/27/2022, indicated on 4/26/2024, the OA signed the JD, indicating the OA was the Medical Records Supervisor/Coordinator. A review of the JD titled, “Office Assistant,” dated 1/27/2022, indicated on 7/8/2024, the OA signed the JD, indicating the OA was the office assistant. During a concurrent interview and record review on 12/3/2024 at 3:30 pm, the Payroll and Admissions Coordinator (PAC) reviewed the OA’s Punch Detail Report (PDR). The PAC stated the OA worked in tangent with the (new) DSD but did not know what the OA’s title was. During an interview on 12/3/2024 at 4:05 pm, the OA stated the OA used to be a LVN, but no longer worked in a LVN capacity because the OA, “Lost his license”. During an interview on 12/3/2024 at 4:38 pm, the ADM stated the OA was working in the facility as the DSD, but the OA’s license was revoked and had been working as an office assistant since 4/2024. The ADM stated the OA was being investigated by the BVNPT for working as a DSD when the OA did not have a license to do so. During an interview on 12/4/2024 at 11 am, the ADM stated that the OA was working as the facility’s DSD from at least 10/2023 until 4/25/2024. The ADM stated the ADM found out the OA’s license expired on 12/31/2023 when the ADM received a call from BVNPT on 4/25/2024, and the ADM pulled the OA from the DSD role. The ADM stated when the ADM asked the OA why the OA was working with an expired license, the OA, “Provided excuses,” before sharing the OA surrendered his license on 1/1/2024. The ADM stated the ADM looked up the OA’s license and learned it was surrendered on 10/27/2023. The ADM stated part of the DSD’s JD was to be in charge of ensuring everyone’s licenses (for licensed nurses) and certifications (for certified nurse assistants [CNA]) were current and the OA did not disclose to the ADM his license had been surrendered. The ADM stated as the DSD between 10/27/2023 to 4/25/2024, the OA could have been providing direct patient care to residents because as the DSD, the OA would cover for licensed nurses when needed and provided direct patient care training or training to new licensed nurses. During a concurrent interview and record review on 12/4/2024 at 12:28 pm, the ADM reviewed an audit of the eMAR and eTAR between 10/2023 and 4/2024. The ADM stated the OA had signatures in the eMAR and eTAR on 10/28/2023, 10/29/2023, 10/30/2023, 10/31/2023, 11/1/2023, 11/6/2023, 11/8/2023, 11/12/2023, 12/7/2023, 12/30/2023, 3/2/2024, 3/3/2024, 3/14/2024, 3/19/2024, and 3/27/2024, indicating the OA was either administering medications and monitoring residents or training staff on how to administer medications and monitor residents. The ADM stated the signatures in the eMAR and eTAR indicated the OA was providing direct patient care without a license to do so. During an interview on 12/4/2024 at 12:56 pm, the DON stated the DSD, DON, and ADM get an alert in the facility’s application for scheduling shifts when a licensed nurse or CNAs license or certification is due to expire. The DON stated the DON did not get a notification in 12/2023 that the OA’s license was due to expire on 12/31/2023. The DON stated the OA informed the DON and ADM in 4/2024 (can’t recall exact date) that the OA’s license was surrendered and that’s why the OA could not renew his license after 12/31/2023. During a concurrent interview and record review on 12/4/2024 at 1:16 pm, the OA reviewed the OA’s BVNPT and the DCA for the state of California, dated 9/5/2023. The OA stated the OA did not understand that by signing the decision on 9/6/2023, the OA was effectively surrendering his license on 10/27/2023. The OA stated the OA’s lawyer explained the decision and provided a copy of it to the OA, but that the lawyer “Explained everything really fast.” The OA stated the first page of the decision indicated OA’s license was effectively surrendered on 10/27/2023. The OA stated the OA did not tell the ADM or DON the OA’s license was surrendered and then expired. The OA stated in order to train new staff, the trainer must have their nursing license. The OA stated the OA must have a nursing license to administer medication and monitor residents. The OA stated it was possible if the OA signed his initials in the eMAR or eTAR between 10/2023 and 4/2024, the OA was providing direct patient care in the form of administering medications and monitoring residents with the staff the OA was training. The OA stated the risk of providing patient care without a license was that the OA could put the residents’ lives at risk. During a concurrent interview and record review on 12/4/2024 at 4:30 pm, the DON reviewed Residents 1, 2, 3, 4, 5, 6, 7, 8, and 9’s eMAR and eTAR’s. The DON stated if the OA’s initials were signed in Residents 1, 2, 3, 4, 5, 6, 7, 8, and 9’s eMAR and eTAR’s, it indicated the OA administered medications and/or provided monitoring to the residents. The DON stated on 10/28/2023, 10/29/2023, 10/30/2023, and 10/31/2023, the OA monitored Resident 8 for behavior of decreased interest with ADL’s. The DON stated by signing the eMAR, it indicated the OA did the monitoring. The DON stated on 10/28/2023, 10/29/232023, 10/30/2023, and 10/31/2023 the OA monitored Resident 8 for the behavior of sudden fluctuation of mood. The DON stated by signing the eMAR, it indicated