complaint·January 14, 2025

...continued from 9099. Staff left residents in soiled diapers for an extended period of time resulting in injury S17 reported he/she has often arrived for his/her shift to find residents were left wet, dirty, full of feces, and with red bottoms, specifically R6 and their family members were complaining directly to S17. S2 stated he/she has been the only one on his/her PM shift showering residents and has complained to S5. S2 has sometimes witnessed unkept faces, clothes, bedding, and soiled sheets because the AM shift hadn't changed the linen, redness in private areas from being soiled, and resident wounds in memory care. S3 stated that he/she is a Med. Tech. and have found residents on the couch with their entire bottom wet, or dried feces, and redness on their private areas. LPA interviewed W2, W2 stated there's been multiple times where R3's briefs and pants have been wet. On 01/03/24, W2 emailed ED and S8 requesting toileting every three (3) to four (4) hours for R3. W2 discovered there was urine on R3’s depends, pants, and wheelchair seat during a music session and that those discoveries were happening too often and was unacceptable. W3 states that R5 wreaks of urine. W3 changed R5’s soiled wheelchair cushion but was still unsure if the smell was coming from R5’s catheter or colostomy bag. W4 stated that R1’s sheets were soiled on a past occasions; therefore, W4 purchased additional sheets. The facility allowed R5 to leave the facility with another family and there was a hygiene issue. W4 didn't elaborate but was quite upset about the occurrence and it was concerning. W4 thought the incident was a form of neglect. W4 stated that if R1 was in his/her right mind, being constantly clean would be very important for R1. Continued on LIC9099C... ...continued from LIC9099C Staff sleeping during work hours ED stated that S7 may have been sleeping on the second floor during his/her 15-minute break and that S7 has a medical condition. S17 and S18 reported they’ve both seen S7 sleeping when S7 should have been working, and that their co-workers may also be calling to make complaints. LPA and LPM interviewed S18 and he/she stated that a resident was walking by and S7 was snoring, and S18 reported the incident to ED and S5. Although S2 never saw S7 sleeping, S2 stated residents don't want S7 on their assignments and when S7 is working, he/she is also on the phone or watching television in the common areas. LPA reviewed S7's file and did not find any approved accommodations from the facility. Staff screamed at resident S2 said that there was screaming on the second floor coming from S15 who was not treating the residents on the floor with respect. S5 said that there’s no policies about the residents. S18 stated that he/she did not like the way S9 was talking to R2. S18 said that R2 is slow to respond sometimes and maybe the staff needs to be training on how to deal with residents. S18 further stated that another staff, S19, was screaming at a resident R2 on 09/17/24 at 11:30am. S18 stated that resident was refusing to go downstairs to the dining room and S19 started screaming, “You need to go now.” Based on LPA and LPM observations, interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are SUBSTANTIATED . Deficiencies are cited from Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violations within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights and a copy of this report provided to interim ED. ...continued from LIC9099A. Staff are eating residents food S17 alleged that S7 was eating R6’s food. ED and S16 were not aware of the allegation. LPA and LPM interviewed S1. S1 stated that he/she helps residents with lunch and dinner. S2 stated they’ve never seen anyone eating any residents’ food. LPA interviewed Witnesses; W2 stated that he/she didn’t have any other concerns about abuse or the staff's skill level or appropriate treatment. W3 stated it's hard to find someone at the facility sometimes and W3 hasn’t seen anything , W4 feels that the care staff are lovely. Staff is not allowing resident to watch TV S18 alleged that S7 puts the television (TV) on, and watches what S7 wants to watch and not what the residents want to watch. The facility has individual apartments and communal areas with televisions. LPA toured the facility, including the second floor on 09/24/24, 10/24/24 and 12/23/24. Multiple residents were not watching TV; instead, they were primarily engaged in other activities facilitated by the care staff. The second floor is memory care (MC). Residents that are able to communicate, can retreat to their individual apartments or sit in the lounge area where the television is located. A finding that the complaints are UNSUBSTANTIATED mean that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview conducted, appeal rights and a copy of this report provided to ED.