complaint·April 25, 2024

Page 2 Staff allow a resident to be in soiled clothing for extended periods of time At complaint intake on August 30, 2023, the RP reported that on multiple occasions the RP had visited R1 and found R1 to be soaked in urine. On March 4, 2024, LPM Fong spoke with the RP who reiterated that R1 was found to be soaked in urine on multiple occasions and that this was brought to the attention of S4. On March 5, 2024, LPM Fong conducted a continuing complaint visit and observed that R1s MD report and intake Appraisal indicated that R1 was independent in toileting. On that same date, LPM Fong interviewed S2, S3, and S4 – all of whom were confirmed to have been employed during the subject time period. S2 reported having no knowledge of the issue, however, S4 acknowledged that family reported coming to the facility to find R1 soaked in urine. An internal investigation was performed, and it was determined that R1 had been left in urine soaked garments and bed for an extended amount of time. Updated Needs and Services documents from August, 2023, indicated that R1 did require incontinence undergarments and changing. Therefore, the allegation is substantiated. Staff do not properly maintain resident’s bedroom. At complaint intake on August 30, 2023, the RP reported that during multiple visits, R1's room was found to have urine soaked clothing and bedding strewn about and with strong urine smell. On March 5, 2024, LPM Fong interviewed S2, S3, and S4 – each stated having no knowledge of R1s room not being properly maintained, cleaned, or serviced. On March 8, 2024, LPM Fong spoke with W1 (neutral witness) who reported having visited R1 at the facility mid-morning and found the room to smell strong of urine – to the point where W1 could not stay in the room. W1 also reported that the laundry basket was full of urine soaked items and that W1 pulled the basket out of the room and requested staff to remove and launder. Therefore, the allegation is substantiated. ......continued on 9099C (page 3) Page 3 Staff do not meet a resident’s incontinence needs while in care. Per the above, at intake the RP reported that R1s incontinence needs were not being maintained. On March 5, 2024, LPM Fong interviewed S2, S3, and S4. S3 reported being on the early morning shift and on multiple occasions immediately found R1 to have been left in urine soaked clothing and bedding. S3 stated that the NOC shift had not properly checked and changed R1 as needed prior to S3’s arrival, therefore, the allegation is substantiated. Staff did not safeguard resident’s personal belongings. At complaint intake, RP reported that R1s undergarments and assistive walking devices had gone missing, with no explanation. On March 5, 2024, LPM Fong interviewed S2, S3, and S4. S2 and S4 reported having no knowledge any items belonging to R1 going missing. However, S3, reported that on multiple occasions staff found that R1s assistive walking device was missing – sometimes it was found, other times it was not, or was found having been destroyed. S3 confirmed that family had to purchase a new assistive walking device, therefore the allegation is substantiated. Staff do not properly maintain the facility grounds. At complaint intake, the RP reported visiting the facility on multiple occasions and observing urine smell in common areas. On March 4, 2024, LPM Fong interviewed S1, S2, S3, and S4 who denied knowledge of urine smell or other maintenance issues. On that same day, LPM Fong observed a strong urine smell in the common area near the secondary/back exit from Memory Care. Therefore, the allegation is substantiated. Staff inappropriately removed a resident’s hygiene products while in care. At complaint intake, the RP reported having visited the facility and found that all of R1s personal hygiene products had been removed from the room. On March 5, 2024, LPM Fong interviewed S2, S3, and S4 – with S2 and S4 stating that there had been staff persons who took it upon themselves to remove and lock the residents’ hygiene products. R1’s Service Plan indicated R1 is able to keep non-toxic products (hand and body soap, toothpaste, shampoo) in R1’s room Therefore, the allegation is substantiated. .......continued on 9099C (page 4) Page 4 Staff did not provide adequate supervision to a resident while in care. At complaint intake, the RP reported that on December 5, 2023, RP found R1 half-naked and wedged between the bed and the wall and that R1 had been able to exit the facility unsupervised (from the Memory Care Unit). On March 5, 2024, LPM Fong interviewed S2, S3, and S4, with all stating having no knowledge of either incident. No witnesses were identified. On that same day, LPM Fong observed that an incident report dated April 11, 2023, was submitted to CCLD indicating that 3 residents (including R1) had been able to exit the Memory Care unit on April 5, 2023. Two of the residents were found in the stairwell; however, R1 was not observed until 15 minutes later when staff noted R1 outside of the facility. LPM Fong reviewed the MD report which confirmed that R1 could not leave unassisted. Based on information obtained, the allegation is substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from Title 22 California Code of Regulations and listed on 9099Ds. Failure to submit proof of corrections by plan of correction due dates and any repeat violation within 12 month period may result in civil penalties. Deficiencies and plan and proof of correction were discussed with the LaTiana James. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided. Page 2 At complaint intake, the RP reported that R1 had been able to exit the Memory Care unit and the building without supervision. RP further reported being able to exit Memory Care by pushing the door, and that it was not secure. On March 5, 2024, LPM Fong observed that the main entry to Memory Care is accessed by taking the elevator to the second floor, and that an electronic key fob is needed to release the entry/exit door. From the inside, LPM Fong again found that the key fob is required to release the door. LPM Fong found that there is a second, back door exit leading to a stairwell that exits at the ground level. This secondary door was found to be a delayed egress. During interview, S1, S2, S3, and S4 stated having no knowledge of there being a maintenance issue with the Memory Care unit doors and no other witnesses were identified. It is undetermined whether R1 had been able to exit specifically due to failure to secure the facility grounds. Based on information gathered, the allegation is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiency cited. Exit interview conducted and copy of this report provided.