complaint·November 1, 2023

Staff are not ensuring resident can reach their call button. - SUBSTANTIATED During a visit to the facility LPA observed that R2's call light was missing the cord. LPA observed a button on the wall without a cord that would normally enable a resident to pull rather than having to be right against the wall to press their call light. 1 of 3 staff stated that some care givers pull Resident 2’s (R2) bed away from the wall so R2 cannot reach their call button. 1 of 3 staff stated If R2 is in their wheelchair they can’t reach their call button. 3 of 3 staff stated that R2’s call light is broken. The string is missing from R2’s call light, there is a red cover that says EMERGENCY on it but R2’s is broken so R2 has to push a tiny knob up or down. R2’s call light just has a button on the wall and R2 has to be in their bed and the bed has to be fully against the wall in order for R2 to reach their call light. It was determined that R2’s call light is missing the cord that would enable R2 to activate their call light even if their bed is not right against the wall. R2 cannot reach their call button unless they are in their bed right against the wall. This allegation is substantiated. Based on interviews, observation and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview was conducted and the report was provided to administrator Michelle Hernandez and Diania Bingham. Page 1 Residents are not showered timely. –- UNSUBSTANTIATED It was reported that residents do not get showers timely. LPA reviewed care tracking sheets for 5 residents for the month of August 2023. 3 of 5 residents received all scheduled showers for the month. 2 of 5 residents showers were not completed twice in 30 days. Residents have the right to refuse showers and any resident who is on hospice may not have showers logged because facility staff are not providing those showers and do not log them. 2 of 3 staff stated residents are showered every two days. 1 staff stated sometimes they run behind but they get the showers done. Administrator stated residents have a shower schedule for twice a week for each resident unless they deny a shower. Chief of Operations stated Residents are showered twice a week depending on the resident’s care plan, staff follow the care plan. A resident can refuse, they have a right to. Staff are doing the showers and they keep approaching a resident if they refuse. It was determined that residents are showered timely unless they refuse. This allegation is unsubstantiated. Continued on LIC9099-C Page 2 Residents miss meals due to staff not transporting them to dining room. - UNSUBSTANTIATED It was reported that residents are not brought down to the dining-room and those residents do not eat. LPA reviewed care tracking sheets for 5 residents for the month of August 2023. Records revealed that residents are served breakfast, lunch and dinner, and 5 of 5 residents ate all of their meals with a few exceptions. There was no pattern of residents not receiving their meals consistently. 3 of 3 staff stated residents are transported to the dining room for meals if they want to go. 3 of 3 staff stated if a resident chooses to stay in their room they are brought their meals. Administrator stated The only ones who are not going are the ones on hospice. We deliver their meal tray to their room. We won’t get them out of bed if they are in a lot of pain. Chief of Operations stated Maybe 6 or 7 residents need to be transported to the dining room for meals. I told staff if a resident doesn’t want to get up at 7am for 8am for breakfast they can make them breakfast later. They have a right to eat when they want to. We bring them a tray if they are not up to going to the dining room. It was determined that residents that need to be transported to the dining room for meals are transported If a resident chooses to not go to the dining room they are being served their meals in their rooms. This allegation is unsubstantiated. Continued on LIC9099-C Page 3 Facility failed to seek timely medical assistance for a resident. – UNSUBSTANTIATED It was reported that Resident 1 (R1) has a wound on the back of their head and RP does not think any wound care is being provided. On 09/06/2023 LPA visited the facility and observed a scab on the back of R1's head. LPA reviewed hospice care plan for R1 which showed R1 was being treated for abscess on 08/23/2023. On 9/26/2023 hospice nursing notes state “Abscess to the back of head resolved with no skin issues noted.” 3 of 3 staff stated that R1 has a wound on their head and is being treated by their hospice nurse for the wound. Administrator stated R1 has a wound on their head, is on antibiotics and the hospice nurse is addressing the wound. Chief of Operations stated it was reported to hospice and the nurse came in, said it was boil and started R1 on antibiotics and provided care. It was determined that R1 has been receiving wound care from their hospice nurse for the abscess on the back of their head. This allegation is unsubstantiated. Continued on LIC9099-C Page 4 Staff did not follow residents special diet order. – UNSUBSTANTIATED It was reported that Resident 3 (R3) is supposed to have a liquid, thickened diet and pureed food and staff are not providing this to R3. LPA reviewed a fax from the facility to the hospice agency reporting that R3 had been choking on food and drinks and needed speech therapy. The hospice agency ordered a pureed diet and thickened liquids as a result on 8/24/2023. R3’s Care tracking sheet revealed that R3 is provided Ensure in between meals. 3 of 3 staff stated Resident 3 is on pureed food and nectar thick liquid. 3 0f 3 staff stated the kitchen is pureeing R3’’s meals. 2 of 3 staff stated that thickener is being added to liquids. Administrator stated R3 is on a liquid, thickened diet and pureed food and the facility is providing the required modified diet for R3. Chief of Operations stated R3’s diet is pureed food with thickened liquids, no consistency. It is posted in the kitchen and dining room, it was well communicated. It was determined that the facility is providing R3 with the special diet as prescribed by the hospice agency. This allegation is unsubstantiated. Continued on LIC9099-C Page 5 Residents are being left in soiled diapers. UNSUBSTANTIATED It was reported that staff is not toileting residents during the PM shift. LPA reviewed care tracking sheets for 5 residents for the month of August 2023. There were no specific abnormalities noted regarding toileting duties not being fulfilled. 3 of 3 staff stated they did not know if residents are being toileted regularly during the PM shift. Administrator stated that residents are being toileted on the PM shift and staff have care plans and charting that they have to do for this task. This allegation is unsubstantiated. Staff smoke marijuana at the facility. - UNSUBSTANTIATED It was reported that staff smoke marijuana on their breaks and then come back and work with the residents. 2 of 3 staff stated they did not know if staff were smoking marijuana at the facility. 1 of 3 staff stated they had heard that staff were smoking marijuana at the facility. Administrator stated It was brought to their attention, they have been watching cameras every day and have not seen anything. Chief of Operations stated There was a rumor that it happened on a PM shift. Someone was bragging about it. We checked the cameras, but we don’t have a camera in the parking lot. I asked all staff if they had seen it and they all said they heard about it but didn’t see it. It was determined that no one witnessed staff smoking marijuana on their breaks and that it was a rumor. This allegation is unsubstantiated. Continued on LIC9099-C Page 6 Staff are taking photographs and video of residents and sharing with one another. - UNSUBSTANTIATED It was reported that staff are taking photographs and video of residents and sharing with one another. 2 of 3 staff stated that there was a staff who had taken photographs of the residents but It was reported to management and then the staff person quit their job. 1 of 3 staff stated they had not heard of staff taking photographs and video of the residents. Chief of Operations stated I received a phone call and was asked if staff could be on Face Time in the facility. The med tech was face timing with their daughter in the community, and said you couldn’t see any residents. The staff person denied that they took a photo of residents. I posted “No phones allowed, protected community, you are not allowed to take video of people in the community.” It was determined that one Med Tech admitted to using Facetime to communicate with their family while inside of the facility. Two staff stated that there was a staff member who had taken photographs of residents, it was reported to management and that staff subsequently quit. There is no evidence that videos or photographs of residents were shared among staff. This allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. Exit interview conducted and a copy of the report was provided to administrator Michelle Hernandez and Diania Bingham.