complaint·March 28, 2025

LIC9099-C (Page 2) Shower Schedules - AL and MCU (Updated 09/14/2023 and 10/04/2023, Facility Registry, E-mail for missing items for 1 resident, LIC 621 Client/Resident Personal Property and Valuables for 1 resident, Hospice Documents, Staff and Resident Rosters for 2025. Allegation: Staff mishandled resident's supplies. Finding: Substantiated On 11/06/2023, LPA interviewed witnesses (W) W1. W1 stated that R1 is on hospice and that hospice orders supplies for R1. W1 stated that the R1’s supplies are not left in their room and that when the hospice nurses come that can find the supplies. W1 stated that they were told that other residents can obtain and get access to the supplies. On 11/07/2023, LPA interviewed staff (S) S1. S1 stated that the facility has a program for incontinence supplies, “TENA” Program, which we order brief incontinence supplies for $125/mo. S1 stated that they have a lot of supplies, so we don’t have to use others. S1 also stated that they will buy supplies and then bill back to residents. S1 stated that supplies are locked in the Med Tech rooms and that only Med Techs have the keys. On 11/07/2023, LPA interviewed W3. W3 stated that R1’s supplies are missing from their room, and it has been ongoing. In addition, W3 stated R1’s personal items have also disappeared. W3 stated that they have labeled clothing, towels, sheets and 80% disappears. W3 stated that they have contacted Westmont but no response. W3 stated that Westmont finally responded and agreed to replace items. LIC9099-C Continued... LIC9099-C (Page 3) LPA reviewed corresponding e-mail dated 10/25/2023 between Executive Director and W3 indicating that the facility will place an order through Amazon to replace missing items. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted. Appeal Rights and a copy of this report provided. LIC9099-C (Page 6) Shower Schedules - AL and MCU (Updated 09/14/2023 and 10/04/2023, Facility Registry, E-mail for missing items for 1 resident, LIC 621 Client/Resident Personal Property and Valuables for 1 resident, Hospice Documents, Staff and Resident Rosters for 2025. Allegation: Staff did not maintain accurate records on the resident. Finding: Unsubstantiated On 11/06/2023, LPA L. Alexander interviewed witnesses (W) W1 that stated that information was second hand from the patient's hospice providers. W1 stated that there were challenges gathering accurate reports of patient ADLS due to limited availability of staff and incomplete records, i.e., last bowel movement. On 11/08/2023 and 03/11/2025 LPA attempted contact with W2 and W3 and left messages for a call back in order to get further information. W2 and W3 have never returned calls after attempts. On 03/28/2025, LPA interviewed S2 and S4 that stated they have meetings with the next shift caregivers to report what happened during their scheduled shift. LPA interviewed S5 that stated the caregivers will inform the med techs and that the med techs will document in the resident's care notes an exception; for example resident did not have a bowel movement during the end of the day. Allegation: Staff did not meet resident's diapering needs. Finding: Unsubstantiated LIC9099-C Continued... LIC9099-C (Page 7) W3 stated that R1 was in the hospital in September. W3 stated that the family was notified of two (2) wounds on R1’s rectum and that the facility never informed the family. On 03/28/2025, LPA interviewed S2 and S4. S2 stated that during the "crossover meeting" that is when the caregivers report to each other the status of each resident. S2 stated that they strat their rounds by checking R1's diapers and if diaper was wet and soiled they will clean and change him. S4 stated that the first thing that they will do is check R1's diaper and if they were wet, they will change their diaper. S4 stated that they will check R1's diapers every 2 hours during their shift. LPA reviewed R1’s Service Plan (dated 05/19/2023) and need assessment indicated full assistance incontinent of bladder and bowels with proper personal hygiene daily. Allegation: Staff did not meet resident's hygiene needs. Finding: Unsubstantiated W3 stated that R1’s bed pads are not changed. W3 stated that if R1 has a bowel movement (BM) they are still not cleaned. W3 stated that R1’s fingernails and toenails were digging into his flesh. On 03/28/2025, LPA interviewed S2 and S4. S2 stated that they would give R1 a bed bath, feed him, make sure that R1 is dry and had no bed sores during their shift. S2 stated that R1 would not have a soaking diaper and they made sure that R1 was clean. S4 stated that they will shave R1 and give R1 bed bath. S4 stated that during 2023, the outside agency would come and give R1 a shower or bed bath. S4 stated that most residents are scheduled showers 2 times a week and some refuses to shower. S4 stated that during their shift R1 was cleaned up after wet soiled diaper changes. LIC9099-C Continued... LIC9099-C (Page 8) LPA reviewed MCU’s shower schedule (updated 10/04/2023) and observed that R1 was not on the shower schedule. LPA reviewed R1’s Service Plan (dated 05/19/2023) and observed that full assistance bathing is 2 times a week, full assistance grooming daily, full assistance daily oral care Allegation: Facility does not have sufficient staff to meet the needs of the resident. Finding: Unsubstantiated W1 stated that sometimes there is one (1) staff to maybe twenty (20) some patients, specifically memory care unit. On 03/28/2025, LPA interviewed S2, S3, and S4. S2 stated that on their shift they have been responsible for 5-6 residents. S2 stated that on their shift there were four (4) caregivers. S3 stated that in 2023 there wasn't as many staff at times but today there's not staffing issue. S3 stated during their there would be approximately four (4) caregiver aides available. S4 stated that there are four (4) staff on their shift. S2, S3 and S4 all stated that there were always staff available on their shifts and never had any issues completing their care needs to residents. LPA reviewed the October 2023 staff schedule for AM, PM and NOC shifts and three (3) to four (4) caregivers were scheduled on each shift. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED . No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.