Complaint·August 11, 2023

Allegation: Resident’s room is unsanitary Investigation Finding: Substantiated Continuation... W1 stated she reported these conditions to executive director (ED) who stated he would handle with staff. W1 visited R1 again on 12/01/21 with the bathroom in the same unsanitary condition, stained rugs not removed and washed. On 01/22/22, W1 visited R1 and found poop on the toilet and pajamas full of poop thrown in the shower. Based on interviews and record reviews which were conducted, the preponderance of evidence standard has been met and the above allegation(s) that resident’s room is unsanitary was found to be substantiated. Allegation: Resident’s hygiene needs are not being met Investigation Finding: Substantiated During investigation, witness (W1) stated family visited resident (R1) at the facility on several dates (11/30/21, 12/06,21) and reported to staff that R1 had not had a shower with hair greasy. W1 stated R1 was finally showered by staff on 12/07/21. W1 stated that from 12/10/21 until 12/13/21, R1 was again not given a shower. ED stated a care conference was held with W1 and R1’s family on 12/15/21. R1’s shower schedule was discussed as well as R1’s weight loss and meal menu. W1 stated staff showered R1 on 01/06/22. Review of R1’s care plan showed R1 required full assistance with weekly showering, wash, shampoo and dressing/undressing to maintain good personal hygiene and cleanliness. On 02/12/22, W1 stated she visited R1 and found her hair greasy again, she had no underwear on and was full of poop. W1 stated the bathroom floor had dried poop and asked staff to clean the room asap. Rather than wait for staff to show up, W1 and W2 stated they gave R1 a shower, washed her hair and placed clean underwear on her and fresh clothes. Continued on next page, LIC 9099-C Allegation: Resident’s hygiene needs are not being met Investigation Finding: Substantiated Continuation... LPA reviewed photos on 06/21/22 which showed R1 with matted, greasy hair, underwear full of fecal matter, dried fecal stains on wall, chair and rug. Review of R1’s care plan showed staff will assist resident to set up toothbrush and toothpaste for oral care at least 2X per day with occasional reminders/cues with using toothbrush/toothpaste/floss or denture maintenance. LPA reviewed a photo of R1’s dental decay when R1’s family took her to the dentist for dental cleaning on 05/23/22. Based on interviews and record reviews which were conducted, the preponderance of evidence standard has been met and the above allegation(s) that resident’s hygiene needs are not being met was found to be substantiated. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties . Exit interview conducted. Appeal rights and a copy of this report provided . Allegation: Facility staff failed to provide adequate care and supervision, resulting in resident sustaining significant weight loss Investigation Finding: Unsubstantiated Continuation... LPA reviewed R1’s care plans which showed her weight in January 2022 at 99.8 pounds and 87.2 pounds in May 2022. W1 stated R1’s weight was at 80.6 pounds. LPA observed R1’s medication records showed R1’s primary care physician prescribed R1 to drink ensure nutritional shakes twice daily with a start date of 02/10/2022. Review of R1’s care plan dated 03/28/22 show a care conference was held by staff and her medical provider to address R1’s weight loss and lab work was ordered. Staff stated R1 refused to eat lunch and dinner due to poor appetite. Review of R1’s care plan dated 06/22/22 show staff provided R1 with nutritional shakes ordered by the doctor daily at 8AM, 12PM, 5PM. Staff stated R1 also had snacks twice daily. Based on interviews and record reviews which were conducted, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff failed to provide adequate care and supervision resulting in resident sustaining significant weight loss is unsubstantiated. Allegation: Facility is providing inadequate food service Investigation Finding: Unsubstantiated During investigation, LPA interviewed staff (ED, S1) who stated that they implemented resident’s (R1) care plan which was full assist with special diet, providing a nutritional shake ordered by the doctor daily at 8AM, 12PM, 5PM and as needed. Staff (ED, S1) stated R1 does not eat much and refuses to drink all flavors of ensure nutritional shakes because she dislikes the taste. Staff stated they provided R1 with food that she likes such as egg, fruit, dessert. R1 also had snacks twice daily. Staff stated that despite their efforts, R1 continued to lose weight due to poor appetite. Staff (S1) stated they are cutting R1’s food at each meal and assisting her with setting up her food while in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that facility is providing inadequate food service is unsubstantiated. Continuation on next page, LIC 9099-C Allegation: Resident’s laundry needs are not being met Investigation Finding: Unsubstantiated During investigation, LPA reviewed housekeeping schedules which showed weekly laundry was provided by staff to all 24 memory care residents to keep all clothing and linens clean. Staff (ED) stated each residents’ clothing, beddings, linens and towels were kept in dedicated laundry baskets that were laundered and delivered back by staff weekly. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that resident’s laundry needs are not being met is unsubstantiated. Allegation: Facility restroom is in disrepair Investigation Finding: Unsubstantiated During investigation, staff (ED) stated that on 05/01/22, the common hallway restroom toilet was reported clogged. LPA confirmed with staff (S2) that the common hallway restroom toilet was unclogged the same day. On 06/22/22, LPA observed common hallway restroom toilet was not clogged, flushing properly and in good repair. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that facility restroom is in disrepair is unsubstantiated. Exit Interview conducted and a copy of this report provided.