complaint·November 20, 2024

...continued from LIC9099. Allegations: SUBSTANTIATED Staff did not ensure residents room was kept safe, clean, and sanitary Staff did not ensure residents personal belongings were safely secured Staff did not ensure residents records were properly maintained Staff did not ensure residents medications were properly managed Staff did not ensure residents medications were dispensed as prescribed Staff did not ensure residents room was kept safe, clean, and sanitary. W1 reported during a visit the weekend of May 17 , 2024, R1's room was found with the waste basket overflowing with used depends, clothes and papers strewn over the bed, the room hadn't been vacuumed, laundry was undone, the bedding hadn’t been changed, and there was mold growing on R1’s plates that were left in the kitchen sink and open containers of food on the counter tops. S2 stated that it should not had mattered if cleaning is the job of housekeeping, R1’s room was untidy and R1 needed to be relocated for cleaning March 2024. S12 reported that the staff keep reporting things to S1 and nothing was being done, therefore the allegation is substantiated. Staff did not ensure residents personal belongings were safely secured. The above allegation refers to the facility not having an adequate policy in place to track residents’ laundry to prevent frequent losses of R1’s clothing which were either never returned or mistakenly worn by other residents according to W1. W1 and S2 stated that on that day of R1’s move-out, the caregivers on duty did not know which laundered items belonged to R1. The items are supposed to be labeled but normally are not, therefore the allegation is substantiated. Staff did not ensure residents records were properly maintained. R1 is diabetic and R1’s Functional Evaluation states that the MedTech is to cue R1 to perform a Finger Stick Blood Glucose (FSBG) test twice daily and there’s not any record of performance or denials of FSBG. The document created by S3 to capture R1’s blood sugar, only recorded the dates from 06/24/2024 to 07/23/24 out of the entire time of R1’s residential agreement from 11/22/23 to 08/10/24 therefore the allegation is substantiated. Continued on 9099C... ...continued from 9099C. Staff did not ensure residents medications were properly managed. Per W1, S1 stated that R1’s critical medical documents were faxed to an unsecured public area. LPA, LPM and S7 toured the facility and there are not any facsimiles that were accessible to the public. S1 is no longer employed at the facility; however, LPA was able to review R1’s records and confirmed that a document for R1’s blood sugar was created by S3 per W1, S2, and S7; the document captured the dates of 06/24/2024 to 07/23/24 during R1’s residential agreement from 11/22/23 to 08/10/24 and there are no other documents for R1, therefore the allegation is substantiated. Staff did not ensure residents medications were dispensed as prescribed. Per W1, S1 stated that R1’s critical medical documents were faxed to an unsecured public area. LPA, LPM and S7 toured the facility and there were not any facsimiles that were accessible to the public. S1 is no longer employed at the facility; however, LPA was able to review R1’s records and confirmed that a document for R1’s blood sugar was created by S3 per W1, S2, and S7. S3 provided the electronic Centrally Stored Medication and Destruction Records for March 2024; when compared with the Medication Sheet for March 2024 it is inconsistent for the medication (Metformin) being dispensed or refused on the following dates of 03/19 - 03/25/2024 and 03/27 - 03/31/2024 therefore the allegation is substantiated. Continued on 9099C... ...continued from 9099C. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. An immediate civil penalty of $250 is hereby assessed for a repeat violation times two (2). Deficiencies are cited from Title 22 California Code of Regulations and listed on 9099D. 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. Exit interview conducted, Appeal Rights, and a copy of this report provided to ED. ...continued from 9099. Staff did not ensure resident received adequate laundry services. W1 presented photos of R1’s room the weekend of May 17, 2024, and none of the photo’s presented not laundered clothing or bedding. S12 presented photos of R1’s room on March 2, 2024, and none of the photo’s presented not laundered clothing or bedding. Although the bedding had clothes and paper strewn on top, LPA could not confirm or deny if the clothes or bedding were not laundered. After interviewing S2, S12 and W1. Interviews revealed the primary complaint was R1’s kitchen being uncleaned, therefore the allegation is unsubstantiated. Staff did not ensure resident received personal mail parcels. LPA observed S13 sorting mail. LPA had a conversation with S13 about trying to catch-up on all the different mail that came in over the weekend. W1 stated that R1's Google camera was missing and never delivered to R1 and provided a tracking number. LPA requested proof of delivery to the facility from W1. S1 is no longer employed for an interview regarding investigation of the missing parcel. After file review, LPA did not observe any complaints or a history of missing parcels, therefore the allegation is unsubstantiated. Staff did not ensure residents dietary care plan was properly followed. LPA toured the facility and observed a white board and dietary binder that listed the names and conditions of residents with dietary restrictions. S10 was aware that R1 was diabetic, and confirmed that S1, S10 and the kitchen staff met monthly to determine if meals needed to be modified or changed. S10 confirmed that the staff could not deny residents food but would steer them from carbohydrates, therefore the allegation is unsubstantiated. A finding that the complaint is unsubstantiated means that the allegations are not valid because the preponderance of the evidence standard has not been met. No deficiencies cited . Exit interview conducted, Appeal Rights, and a copy of this report provided to ED.