complaint·June 30, 2023

ADM stated they later contacted authorized representative (POA) several times to pick up R1’s remaining misplaced personal items (wall décor wreath, Black IPad and photo album) left at the facility with no response from POA. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff did not safeguard R1’s belongings was found to be substantiated. Deficiency is 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: Resident developed pressure injuries due to staff neglect Investigation Finding: Unsubstantiated Continuation: On 01/03/23, R1 developed a new skin issue on her right heel (stage 1) and a redness on her left heel. On 01/10/23, the right heel wound developed into a stage II/III pressure injury. Staff implemented hospice care instructions on how to offload pressure on heels. On 01/11/23, hospice care team nurse observed the right heel pressure injury was a stage 1. Blister was wrapped in a kerlix and there was redness on the left heel. No new skin issue was noted by hospice nurse. 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 developed pressure injuries due to staff neglect is unsubstantiated. Allegation: Staff did not provide adequate assistance to resident in a timely manner Investigation Finding: Unsubstantiated During investigation, IB Investigator confirmed with Home Health and Hospice care team that R1 was on Home Health and Hospice Care from 06/10/22 to 01/12/23. Review of hospice records show that R1 received care and supervision by hospice care team (RN, LVNs, NP) while in hospice care. Staff (ADM, S1, S2) stated they implemented R1’s hospice care plan as instructed by the hospice care team. 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 did not provide adequate assistance to resident in a timely manner is unsubstantiated. Allegation: Staff did not get resident’s representative’s permission prior to performing a medical procedure on resident while in care Investigation Finding: Unsubstantiated During investigation, staff (ADM) stated that staff implemented hospice care instructions on how to offload pressure on R1’s heels by elevating her feet with foam or pillow supports. ADM stated that any invasive medical procedure on R1 was performed by the hospice care team only. Review of hospice records show hospice team notified and updated R1’s family / primary caregiver and primary care physician regarding R1’s condition on 12/29/22, 01/03/23, 01/10/23, 01/11/23 and 01/12/23. 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 did not get resident’s representative’s permission prior to performing a medical procedure on resident while in care is unsubstantiated. Allegation: Staff did not communicate with resident’s representative regarding resident’s change in condition in a timely manner Investigation Finding: Unsubstantiated During investigation, staff (ADM) confirmed with LPA that R1’s authorized representative (POA) was updated on R1’s change in condition while in hospice care. Review of hospice records show hospice care team notified and updated R1’s family / primary caregiver and primary care physician regarding R1’s condition on 12/29/22, 01/03/23, 01/10/23, 01/11/23 and 01/12/23. 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 did not communicate with resident’s representative regarding resident’s change in condition in a timely manner is unsubstantiated. Allegation: Staff did not turn resident as necessary Investigation Finding: Unsubstantiated During investigation, staff (S1) stated that they followed resident’s (R1) hospice care plan as instructed by the hospice nurses. Review of R1’s hospice records dated 01/11/23 show R1 had no new skin issues noted, blister on right heel (currently wrapped in kerlix) and redness on left heel. Staff (S1) stated that R1 was not on a turning scale schedule because R1 can still turn on her own. 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 did not turn resident as necessary is unsubstantiated. Allegation: Staff did not accord resident dignity Investigation Finding: Unsubstantiated During investigation, staff (ADM, S1, S2) denied verbally abusing resident (R1) while in care at the facility. LPA interviewed random residents (R2, R3, R4) who stated that staff treat them well and do not call them names. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore that staff did not accord resident dignity is unsubstantiated. Allegation: Staff did not maintain medical equipment in a sanitary manner Investigation Finding: Unsubstantiated During investigation, staff (ADM) confirmed with LPA that resident (R1) had dedicated use of medical equipment while in care. ADM stated that staff followed resident’s (R1) hospice care plan as instructed by the hospice nurses and sanitized medical equipment as prescribed by the hospice care team. 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 did not maintain medical equipment in a sanitary manner is unsubstantiated. Exit Interview conducted and a copy of this report provided.