Abuelos at La Canada

Based on record review and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis before or within seven calendar days after the resident's date of occupancy, for one of two sampled residents. Findings include: 1. A review of R2's medical record revealed documentation of evidence of freedom from infectious tuberculosis was not available for review. However, based on R2's date of occupancy, this documentation was required. 2. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. Findings include: 1. A review of facility disaster drills revealed disaster drills conducted on both shifts in April 2025. However, documentation of disaster drills conducted no later than July 2025 was not available for review. 2. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on record review and interview, for three of three sampled former resident, the manager failed to ensure a resident's medical record contained the date of termination of residency. Findings include: 1. A review of R2's, R3's, and R4's medical records revealed a date of termination of residency was not available for review. 2. In an interview, E1 and E2 acknowledged the medical records provided for the three former residents had not included the date of termination of residency.

Based on observation, documentation review, and interview, the manager failed to designate in writing a caregiver who is present on the assisted living facility's premises and accountable for the assisted living facility when the manager is not present on the assisted living facility premises. Findings include: 1 . When the Compliance Officer arrived at the facility at approximately 9:30 AM, the Compliance Officer observed E3 and E4 working on the premises. 2 . A review of facility documentation revealed a posted document titled, "Delegation of Manager by the Governing Authority," which included a list of delegated caregivers. However, E3 and E4 were not listed on the delegation. 3. In an interview, E1 reported E3 and E4 were not caregivers and did not have personnel files. 4. In and interview, E1 and E2 acknowledged no documentation had been provided to show E3 or E4 were qualified or authorized to work at the facility.

Based on record review and interview, for one of one sampled resident receiving services from a hospice agency, the manager failed to ensure a resident's medical record contained any information provided by the hospice service agency or a copy of the resident follow-up instructions provided to the resident by the hospice service agency. Findings include: 1. A review of R2's medical record revealed a service plan which stated R2 was receiving hospice services. 2. A review of R2's medical record revealed a document titled, "Monthly ADL's," which had the word "Hospice" written across the section of the form used to document bathing services. 3. A review of R2's medical record revealed a hospice plan of care, biweekly plan of care updates, or any other hospice provided documentation was not available for review. 4. In an interview, E1 and E2 acknowledge the provided record for R2 had not included the required documentation from R2's hospice service agency.

Based on documentation review, and interview, the manager failed to ensure documentation was maintained of the caregivers and assistant caregivers working each day, including the hours worked by each. Findings include: 1. A review of the facility's personnel schedules revealed documentation of of the caregivers and assistant caregivers working each day between December 29, 2024 and March 23, 2025 was not available for review. 2. In an interview, E1 and E2 acknowledged the facility failed to maintain documentation of the caregivers and assistant caregivers working each day, including the hours worked by each.

Based on documentation review, record review, and interview, the manager failed to maintain a personnel record for each employee which included the items required by this rule, for two of two employees sampled. The deficient practice posed a risk as required information could not be verified for an employee. Finding include: 1. During the environmental inspection of the facility, the Compliance Officer observed E3 and E4 working alone at the facility. Approximately 20 minutes later, the Compliance Officer observed E1 arrived at the facility. 2. In an interview, E1 reported E3 and E4 were just covering E1 briefly so E1 could go take a shower. E1 reported E3 and E4 do not have personnel files. 3. A review of personnel records revealed no personnel records for E1 and E2. 4. In an interview, E1 and E2 acknowledged personnel records were not available for E3 and E4 before the end of the inspection.

Based on record review and interview, the manager failed to ensure before or at the time of an individual's acceptance by an assisted living facility, there was a documented residency agreement with the assisted living facility which included the requirements in R9-10-807(D)(1-10) for one of four resident records reviewed. Findings include: 1. A review of R4's medical record revealed a documented residency agreement was not available for review. 2. In an interview, E1 reported the file had been archived and some parts of it had not been readily located. 3. In an interview, E1 and E2 acknowledged the residency agreement for R4 was not available.

Based on record review and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for two of four sampled residents. Findings include: 1 A review of R1's and R3's medical records revealed service plans indicating both residents received medication administration services. 2. A review of R1's and R3's medical records revealed lists of medication orders for each resident. 3. A review of R1's and R3's medical records revealed Medication Administration Records (MAR's) for each resident. However the medications documented to have been administered on the MAR did not match the medication orders, indicating some medications had not been administered as ordered. 4. In an interview, E1 and E2 acknowledged the provided documentation of medication orders and MARs for R1 and R3 indicated medication had not been administered as ordered.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for one of two residents sampled who received medication administration. Findings include: 1. A review of R1's medical record revealed a service plan, updated July 5, 2024, for personal care services including medication administration. 2. A review of R1's medical record revealed a signed list of medication orders dated May 30, 2024, which included orders for the following: - "Alendronate 35 MG Tablet, 1 tablet, oral, weekly"; and - "Docusate Sodium 100 MG tablet, 1 tablet oral, daily." 3. A review of R1's medical record revealed an electronic Medication Administration Record (eMAR) dated September 2024. The MAR documented the medications administered to R1 during the month of September, 2024. However, the eMAR documented the following: - "Alendronate 35 MG, Take one TAB PO Q Weekly," had been marked as administered on every day in September 2024; and - "Docusate Sodium," was not included on the eMAR. 4. In an interview, E2 acknowledged the eMAR provided for R1 did not accurately document the medications administered to R1.

Based on observation, record review, and interview, the manager failed to ensure that medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to residents who were unable to self-administer medications. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a cabinet located in the kitchen was used to store medication. The cabinet had a lock, however, the key had been left in the lock. 2. During an environmental inspection of the facility, the Compliance Officer observed a cabinet located in the living room was used to store medication. The cabinet had a lock, however, the cabinet was found to be unlocked during the environmental inspection. 3. During an environmental inspection of the facility, the Compliance Officer observed a container of "Gelmicin," an antibiotic cream, and a tube of barrier cream, in the unsecured medicine cabinet of a shared bathroom. 4. In an interview, E2 acknowledged medication required to be stored by the assisted living facility had not been stored in a locked area. This is a repeat deficiency from the on-site compliance inspection conducted on September 28, 2023.

Based on observation, record review, and interview, the manager failed to ensure that medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a cabinet located in the kitchen was used to store medication. The cabinet had a lock, however, the key had been left in the lock. 2. During an environmental inspection of the facility, the Compliance Officer observed a container of petrolatum jelly in R1's bedroom on a table next to a bed. 3. A review of R1's medical record revealed a service plan for personal care services including medication administration. However, R1's service plan did not state R1 would store any medication in R1's room. 4. In an interview, E1 acknowledged medication required to be stored by the assisted living facility had not been stored in a locked area.