Always Tlc

On September 4, 2024, Licensing Program Analyst (LPA) Murial Han and Komal Charitra conducted an unannounced plan of correction visit to follow up on a civil penalty that was assessed on 8/20/2024. LPA met with caregiver, Doris Mores and explained the purpose of the visit. The administrator arrived shortly thereafter and assisted with the visit. On 8/ 20/2024, LPA Han conducted an unannounced Plan of Correction visit to follow up on the citations that were issued during the annual inspection on 8/6/ 2024. During the visit, LPA reviewed and validated the plan of correction that was submitted by the administrator/licensee and cleared 9 out of 12 citations However, LPA observed the remaining citations- 1569.695(c) ; 87608(a)(5)(B); 1569.625(b)(2) were not corrected and due to the citations not being corrected, a civil penalty in the amount of $3300 was assessed from 8/8/2024 - 8/20/2024. During today's visit, LPAs reviewed the plan of correction for the following citations: - 1569.695(c)- Emergency drill was conducted on 8/23/2024 and the administrator stated that it will be conducted on a quarterly basis. - 87608(a)(5)(B)- Physician orders were obtained for the residents who have a bed rail by the head of the bed. - 1569.625(b)(2)- Annual training was started for staff on 8/30/2024 and will continue. Civil penalty is being stopped on 8/21/2024 as the above citations are observed to be corrected. No deficiency is cited today. This report is reviewed and discussed with the administrator and a copy is provided.

On August 20, 2024, Licensing Program Analyst (LPA), Murial Han conducted an unannounced plan of correction visit. Upon entrance, LPA met with caregiver, Doris Mores and explained the purpose of today's visit. The administrator, Tomas Consunji arrived shortly thereafter and assisted with the visit. During today's visit, LPA observed the following deficiencies are corrected: - 87470(b)(2) ; 87202(a) ; 87305(a) ; 87307(d)(6) ; 87456(a)(2) ; 87608(a)(3) ; 87506(b)(17)(E) ; 87456(a)(3); 87458(a) During today's visit, LPA observed the following deficiencies were not corrected: - 1569.695(c) ; 87608(a)(5)(B); 1569.625(b)(2) D ue to the above observation and deficiencies not being corrected, a civil penalty is being assessed in the amount of $100 a day from 8//8/2024 through 8/20/2024 for the deficiencies of ; 1569.695(c) ; 87608(a)(5)(B) and $100 a day from 8/14/2024 through 8/20/2024 for the deficiency of 1569.625(b)(2) and will continue to accrue until corrected. A total civil penalty of $3,300 is being assessed today. This report is reviewed and discussed with the administrator. A copy of this report and the appeal rights were provided.

LPA interviewed staff #1 (S1) who stated that they are aware of the cockroach problem in the facility and the administrator is working with a pest control company to resolve it. LPA interviewed resident #1 (R1) and R1's responsible party who stated that staff does a good job with ensuring the facility is cleaned and tidy and they are aware of cockroaches at the facility and the administrator is actively working with a pest control company to take care of this issue. In addition, R1 stated that the room is always cleaned and staff mops the floor twice daily. Based on documents provided, LPA observed a service slip from a pest control company showing the service was provided on July 27, 2023, and on August 18, 2023, administrator reported to the pest control company that R1 spotted roaches in R1's room which triggered a service scheduled for today (September 5, 2023) and monthly thereafter. Based on observation, interviews and record review, this allegation is unsubstantiated as the facility discovered the problem prior to this complaint and the administrator has been working with a pest control company to resolve the problem. Although the above investigations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. This report is discussed with the administrator who arrived during the exit meeting. A copy is provided.

In addition, the administrator stated that facility staff is trained and educated on caring for residents with diagnosis of Dementia. However, the administrator was not able to provide any training records. This deficiency will be cited on LIC809 and LIC809D under case management. LPA also interviewed R1's responsible party who validated that when the facility realized that they were not capable of providing the level of care that R1 required, the facility contacted the responsible party to seek for other placement and eventually, R1 was transferred to the acute hospital due to a change of health condition where R1 was discharged to a higher level of care. Based on documents provided, the LIC 602A (Physician's Order) and the LIC 603A (Resident Appraisal), it did not indicate R1 has current and/or history of challenging behaviors and both documents were completed prior to R1's admission. Base on record review and interviews during the course of investigation, this allegation is deemed to be unsubstantiated as the facility was not informed of R1's challenging behaviors prior to R1's admission and when the facility learned about these behaviors, the administrator contacted the responsible party to seek for other placement. Regarding to allegation of resident was left in soiled clothing for extended period of time, the reporting party stated that whenever the responsible party visited R1, R1 smelled like urine, and R1 was left in soiled diapers for an extended period of time. As part of the investigation, LPA interviewed the administrator who acknowledged the above allegation. However, the administrator stated that staff attempted to clean R1 multiple times a day but with no success due to R1's refusals and aggression behaviors toward facility staff. LPA also interviewed facility staff members who reported that they attempted to provide Activities Of Daily Living (ADLs) to R1 and attempted to clean R1's room but it was very difficult due to R1's behaviors. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Furthermore, LPA interviewed resident #2 (R2) who stated that R1 needed a lot of help from staff but when staff attempted to help R1, R1 became combative and the facility had an extra staff to help R1. Base on observation, and interviews during the course of investigation, this allegation is unsubstantiated , no neglect was observed. Regarding to the allegation of facility is malodorous, the reporting party stated that when the responsible party visited R1, the responsible party smelled urine and feces in R1's room. As part of the investigation, LPA interviewed the administrator who acknowledged that R1's room had an unpleasant smell as R1 urinated on the floor, and had bowel movements in the closet on a daily basis. Facility staff did the best they could to clean the room and get rid of the odor. LPA interviewed R2 who stated that facility staff do a good job with cleaning and the facility is always cleaned. During the investigation, LPA toured the facility and resident's room and observed it to be cleaned, odorless and tidy. Base on observations and interviews during the course of investigation, this allegation is unsubstantiated. Although the above investigations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. This report is reviewed and discussed with the administrator. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 In addition, the administrator provided a copy of R1's appraisal that was completed on 6/1/2022 (R1 was admitted on 6/4/2022) which revealed R1 has a diagnosis of Dementia but R1's challenging behaviors were not mentioned. Furthermore, the facility provided a copy of R1's Physician's Report which also did not indicate R1's challenging behaviors. After the investigation, the above allegation is deemed to be unfounded as the administrator completed the pre-appraisal prior to R1's admission. Based on record review, and interview during the course of the investigation, this complaint is deemed to be UNFOUNDED, meaning that these allegations were false, could not have happened and/or is without a reasonable basis as during the investigation. This report is reviewed with the administrator. A copy is provided.