complaint·May 2, 2024

Staff did not transport resident in a safe manner – SUBSTANTIATED It was reported that staff were transporting a wheelchair bound resident in the facility van to a medical appointment. When the van came to a stop, the resident fell out of the wheelchair because the resident did not have a seat belt on. RP stated they received a call from the driver, RP went to help but ultimately the fire department had to come and help get R1 back into their wheelchair. R1 sustained some bruising but no injury as a result. LPA reviewed Resident 1 (R1)’s Physicians Report which states that R1 is non-ambulatory. Care staff had no direct knowledge of the incident. Administrator stated they did hear about the incident. When R1 was interviewed, they said they were strapped in but were unsure how the seatbelt came unlatched. It was determined that staff did not ensure that R1 had a seatbelt on while being transported resulting in R1 falling out of their wheelchair in the facility van. Continued on LIC812-C Staff are not bathing a resident in care - SUBSTANTIATED It was reported that a resident is not being bathed. LPA reviewed R1’s Care plan which states that R1 is to shower on Monday, Wednesday, and Friday of each week. LPA reviewed Physician’s Report for R1 which states that R1 must be supervised while bathing and forgets to bathe. LPA reviewed Care Tracking Sheet for R1 which states the resident is full assist with all activities of daily living (ADLs). The ADL category Showers has instructions: Resident needs assistance with transfers into shower chair, resident also needs assistance with helping bathe. According to the Care Tracking Sheet during the month of March 2024 R1 was scheduled for 12 shower days. Resident had showers on 7 of the 12 scheduled shower days. On 5 of the scheduled shower days R1 was not showered with an outcome on “not completed.” LPA reviewed observation notes for the month of March 2024 for R1 and there were no notations of R1 refusing showers. Staff interviews revealed that R1 complained that the staff would not go in his room to help him. Administrator stated R1 refuses showers, if R1 is refusing, we can’t force him to get in the shower. It was determined that R1 is not being bathed according to their care plan. This allegation is substantiated. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview conducted and a copy of the report was provided to COO Diania Bingham. Resident sustained an unexplained injury while in care - UNSUBSTANTIATED It was reported that a resident has a scrape on their buttocks and it is unknown how the resident got the injury. RP states that R1 a bed sore 3 years ago and it just stayed a dry spot. LPA reviewed R1’s Physicians Report which states that R1 has a history of skin condition breakdown and needs help with care. Staff stated that R1 has a very sore bottom but they would not call it a scrape. Administrator stated they had no knowledge about the scrape on R1’s buttocks. It was determined that R1 does not have a scrape on their buttocks but does a history of a previous pressure injury that has stayed as a dry spot, additionally R1 does have issues with rashes in the area. This is not an injury. This allegation is unsubstantiated. Staff are not giving water to residents in care. - UNSUBSTANTIATED It was reported that the residents are not given water at the facility. On the day of the initial visit LPA observed staff rolling a cart through the facility offering water and lemonade to residents. Administrator stated the facility has a hydration cart and do 2-hour rounds where staff goes in and changes the residents and checks on what they need, gives them water. The facility also offers coffee tea and water time at 10:00 am and 3:00 pm every day. It was determined the facility does offer water and soft drinks to residents. This allegation is unsubstantiated. Continued on LIC9099-C Staff are not properly caring for resident's skin rash - UNSUBSTANTIATED It was reported that a resident is supposed to have the cream placed on a rash after each bath/ shower and the staff are not putting the cream on the resident. LPA reviewed R1’s Physicians Report which states that R! has a history of skin condition breakdown and needs help with care. LPA reviewed R1’s MAR for the month of March 2024 which states that R1 was prescribed Calmoseptine External Ointment 0.44-20.6 % with instructions APPLY TO PERINEAL AREA AS NEEDED FOR REDNES /RASH/ EXCORIATION UNTIL CLEARED. This ointment was applied to R1 on 3/12/2024 and 03/18/2024 with an effective outcome noted. R1’s MAR includes Hydrocortisone External Ointment 2.5 % with instructions to apply to affected area of face/groin twice daily for 2 weeks, then one week off, repeat pattern as needed for flares or irritation. This ointment was applied twice daily from the dates of March 1 through March 22, 2024 with the exception of the following dates: 03/05/24 PM dose, 03/06/2024 through 03/07/2024 AM & PM doses, and 03/08/2024 AM dose were not dispensed. Staff interviews revealed that R1 has lots of creams, ointments, barriers, most of the time R1 will let staff apply the creams. Administrator stated R1 has a rash on their groin, the staff go in the morning to change him, they call the med tech who comes in and puts powder or cream on the rash. It was determined that staff are applying the required creams to R1 as indicated in the Medication Administration Record (MAR). 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 violation occurred, and the findings are UNSUBSTANTIATED. Exit interview conducted and a copy of the report was provided to COO Diania Bingham.