complaint·August 29, 2024

Investigation Revealed the Following: #1 Allegation: Resident sustained injury while in care This complaint alleges that (R#1) sustained a wound on the right leg due to a dilapidated bed frame while in care at the facility. This complaint alleges, (R#1) sustained a 6-inch skin tear on the right leg when making contact with a sharp metal piece on (R#1)’s bed frame. LPA was unable to find documented evidence or witness accounts of (R#1) sustaining an injury due to the bedframe being in disrepair. LPA found documentation stating (R#1) experienced an unwitnessed fall in (R#1)’s room at approximately 10:00 p.m., on 9/3/2022, and sustained an injury to the right leg and was bleeding. (R#1) stated the injury occurred when (R#1) was walking to the restroom in the dark and could not see what was in the way when the injury occurred. After the injury occurred (R#1) called for Staff to assist. Staff responded and found (R#1) laying on the floor and (R#1)’s right leg was bleeding. Staff then contacted 911 and EMS responded to the call in approximately (5) minutes. (R#1) was then transported to the hospital. LPA Iniguez conducted an interview with the facility Administrator (A#1) on 3/28/24. (A#1) stated that a family member requested (R#1)’s bed frame be replaced as it was in disrepair, and this caused the injury to (R#1)’s leg. (A#1) stated she inspected (R#1)’s bed frame and found it safe for use; however, she honored the family members request to replace the bed frame. In addition, (A#1) stated that they do not know how (R#1) sustained their leg injury it was unwitnessed. During an interview on 3/28/24 with the Maintenance Director (S#9), he stated that prior to (R#1) 's moving into the facility, he assembled and inspected (R#1)’s room furniture. He did not observe that the bed frame was in disrepair and safe for use. On 10/25/22, LPM Lourdes Montoya conducted interviews with at the facility and found the following: During interviews with residents (R#2-R#10), (9) out of (10) residents did not express concerns about safety in the facility. Evaluation Report continues LIC 9099-C During interviews with (A#1) staff (S#2-S#7), (2) out of (7) facility staff stated they inspected (R#1)’s bed frame and found it safe for use. Out of the (7) staff members interviewed, (6) have not observed residents injured while in care. #2 Allegation: Resident sustained fungal infection. The details of this complaint allege that (R#1) sustained a fungal infection due to lack of showers while residing at the facility from 08/09/22-10/29/22. During the records review, LPA Iniguez reviewed (R#1)’s Service Assessment Plan dated 8/9/22. In this plan, it is written that (R#1) required a level- 7 in Hygiene and Grooming, which means the facility staff must assist them daily with personal hygiene and grooming. In addition, under the Bathing service, (R#1) had a level -10, which means (R#1) would receive assistance with bathing three times a week. In addition, LPA Iniguez obtained and reviewed copies of the facility shower schedules for the period of 8/11/22 until 10/25/22. These schedules reflect the facility staff assisted (R#1) with bathing (3) times per week consistently during the time (R#1) resided at the facility. LPA conducted an interview with (A#1), who stated the cause of the fungal infection was unknown; however, Home Health visited (R#1) daily and cared for (R#1)’s health needs. LPA obtained Home Health care plan indicating, on 10/14/2022, Home Health began applying an antifungal topical medication (R#1)’s legs and the last application for this topical medication ended 10/16/2022. On 10/25/22, LPM Lourdes Montoya conducted interviews with at the facility and found the following: Interviews were conducted with (R#2-R#10), (9) out of (10) Residents were not aware of or observed (R#1) with a fungal infection on the legs. Interviews with staff (S#2-S#7), revealed (6) out (7) were not aware of (R#1)’s fungal infection. Evaluation Report continues LIC 9099-C #3Allegation: Staff did not order prescribed medication for resident The details of the complaint alleged that the facility failed to order (R#1)’s prescribed medication for a fungal infection on (R#1)’s right and left lower legs. During the course of this investigation, LPA Iniguez obtained documentation confirming on an order for Micanazole 2% antifungal cream dated 10/13/22. The detail of this complaint alleges the cream was not ordered or applied to (R#1)’s fungal infection on 10/14/22,10/15/22, and 10/16/22; however, home Health records confirm Micanazole 2% antifungal cream was applied to (R#1)’s fungal infection by a Home Health nurse on 10/14/22,10/15/22, and 10/16/22. LPA reviewed the Medication Administration Record and found a notation indicating Home Health would administer this medicated cream. On 10/25/22, LPM Lourdes Montoya conducted interviews with at the facility and found the following: During interviews with residents (R#1-R#10), (9) out of (10) stated that they were not aware of, nor have they observed medication not being ordered for a Resident. During interviews with staff (S#2-S#7), (6) out of (7) stated they were not aware of, nor have they observed medication not being ordered for a Resident. #4 Allegation: Staff inappropriately handled residents roughly. The details of the complaint alleged that facility staff “hit (R#1) on the face” by Staff S#8, on 10/12/22, when S#8 assisted (R#1) with a shower. LPA conducted an interview with the Administrator (A#1). (A#1) stated that she is aware of this allegation as it was reported to her by (W#1) on 10/12/22. W#1 stated that during a phone conversation with (R#1) on 10/12/22, (R#1) reported the incident to (W#1). Evaluation Report continues LIC 9099-C (A#1) stated on 10/12/22, an Unusual Incident Report and, on 10/13/22, a Suspected Abuse of a Dependent Adult/ Senior (SOC 341) was sent to CCLD. (A#1) stated S#8 was suspended following the report, and the facility conducted an internal investigation. (R#1) was interviewed during the facilities investigation and asked if (S#8) had “hit” (R#1), and (R#1) stated that they did not remember if (S#8) had hit them. S#8 was interviewed and denied “hitting” (R#1) when assisting (R#1) on 10/12/22. The facility found no physical signs of (R#1) having been “hit”. The facility was unable to find evidence to support S#8 “hit” (R#1). (A#1) states the alleged incident was reported to the Torrance Police Department on 10/13/22. The Torrance Police Department officers visited the facility on 10/18/22 and 10/19/022. The officers conducted interviews with (R#1) and staff members. During the police department interviews with (R#1), (R#1) stated that they believe they raised their voice at S#8, but S#8 did not hit them. LPA Iniguez was informed that a report was not going to be created for the alleged incident and there would be no further follow-up. On 10/25/22, LPM Lourdes Montoya conducted an interview with (R#1). R#1 stated that while S#8 aided (R#1) in the shower, on 10/12/22, S#8 was rude and not patient. R#1 did not recall being physically “hit” by S#8 while S#8 provided assistance to R#1. On 10/25/22, LPM Lourdes Montoya conducted interviews with at the facility and found the following: During an interview with Resident (R#1), they stated that they were aware of, nor have they observed facility staff inappropriately handling them roughly. During interviews with residents (R#2-R#10), (9) out of (10) residents stated that they were not aware of, nor have they observed a staff inappropriately handle a resident in care roughly. During interviews with staff (S#2-S#7), (6) out (7) staff stated that they were not aware of, nor have they observed a staff inappropriately handle a resident in care roughly. Evaluation Report continues LIC 9099-C #5 Allegation: Staff screams at residents. The detail of the complaint alleges that facility is not properly trained to work with dementia Residents. During the course of this investigation, LPA Iniguez obtained copies of the 2022 mandatory facility staff training. These trainings included Dignity and Respect, Dementia Training, Dementia and Hygiene, and Personal Rights of all Residents. According to (A#1) statement, new staff shadow the Resident Care Coordinator for two days, followed by shadowing a seasoned caregiver for five days or more as needed. Furthermore, (A#1) stated that to train new staff to work at the dementia unit, they start with 12 hours of video training about dementia care, postural supports, diets, and fall risk. After the two days of video training, they shadow a seasoned caregiver for ten days or more as needed. On 10/25/22, LPM Lourdes Montoya conducted interviews with at the facility and found the following: During an interview with facility administrator (A#1) stated that she has not heard or observed a facility staff screamed at a resident. During an interview with resident 1, (R#1) stated that they have not observed or heard facility staff scream at them. During an interview with residents, (9) out of (10) residents stated that they had not heard or observed a staff scream at a resident in care. During an interview with facility staff, (6) out of (7) staff stated that they had not heard or observed a staff scream at a resident in care. Evaluation Report continues LIC 9099-C #6 Allegation: Staff inappropriately disciplined resident in care The details of the complaint alleged that as a form of punishment, the facility staff prevented (R#1) from participating in activities and meals with peers due to R#1’s “yelling” behavior. During the course of this investigation, LPA Iniguez was interviewed (A#1). She stated that (R#1) could participate in activities offered by the facility, and (R#1) came down to the dining room for breakfast, lunch, and dinner; she barely had a tray requested in their room. (A#1) stated that due to (R#1)'s behaviors, they seemed to have (R#1) to have meals with the dementia unit. Also, (A#1) stated that (R#1)'s POA was aware of their disruptive behaviors and agreed to have them at the memory care unit for their safety and the other residents. On 10/25/22, LPM Lourdes Montoya conducted interviews with at the facility and found the following: During an interview with administrator, (A#1) stated that they informed (R#1)’s POA that the reason they are eating in the dementia unit is because (R#1)’s behavior disrupts the resident’s meals times. During an interview with resident 1, (R#1) stated that they have not heard or observed a facility staff inappropriately discipline them, (R#1) said, "I won't be here if they have." During an interview with residents, (9) out of (10) residents stated that they had not heard or observed a staff inappropriately discipline a resident while in care. During an interview with facility staff, (6) out of (7) staff stated that they had not heard or observed a staff inappropriately discipline a resident while in care. Evaluation Report continues LIC 9099-C #7 Allegation: Staff is not showering resident. The details of the complaint alleged that facility staff are not showering (R#1) on a regular basis per and (R1’s) care plan. During the records review, LPA Iniguez reviewed (R#1)’s Service Assessment Plan Form dated 8/9/22. In it, it is written that (R#1) has a level 7 in Hygiene and Grooming, which means the facility staff must assist them daily with personal hygiene and grooming. In addition, under the Bathing service, (R#1) had a level 10, which means they will receive complete baths up to three times a week with staff assistance. In addition, LPA Iniguez reviewed copies of the shower schedule received on 8/26/24. (R#1) received three weekly showers from 8/11/22 until 10/25/22. On 10/25/22, LPM Lourdes Montoya conducted interviews with at the facility and found the following: During an Interview with the Administrator (A#1), she stated that she had yet to hear or observe facility staff not showering (R#1). (A#1) stated, “Last week (R#1)’s shower day was moved because R#1 did not want to shower. During an interview with resident 1 (R#1), they stated they did not remember if facility staff were showering them. During interviews with residents (R#2-R#10), (1) out of (9) stated that they shower themselves. Also, (8) out of (9) stated that they had yet to hear or observe facility staff not showering a resident. During interviews with staff (S#2-S#7), (6) out of (7) stated that they had yet to hear or observe facility staff not showering (R#1). Evaluation Report continues LIC 9099-C #8 Allegation: Staff do not change resident's clothing. The details of the complaint alleged that facility staff does not change (R#1) on a regular basis and per (R#1’s) care plan. During the records review, LPA Iniguez reviewed (R#1)’s Service Assessment Plan Form dated 8/9/22. In there, it is written that (R#1) has a level 7 in Hygiene and Grooming, which means the facility staff must assist them daily with personal hygiene and grooming. In addition, under AM Care, (R#1) has level 7, which means the facility staff must assist the resident daily in getting dressed. Moreover, under P.M Care, (R#1) has level 8, which means the facility staff must assist the resident to bed occasionally or daily. On 10/25/22, LPM Lourdes Montoya conducted interviews with at the facility and found the following: During an Interview with the Administrator (A#1), she stated that she had not heard or observed facility staff not changing (R#1)’s clothes. Also, (A#1) stated that “last week (R#1) was wearing a dress, but their daughter wanted to wear pants/blouse. During an interview with resident 1 (R#1), they stated they cannot remember if facility staff did not change them. During interviews with residents (R#2-R#10), (1) out of (9) stated that they changed their clothes. Also, (8) out of (9) stated that they had not heard or observed facility staff not changing residents’ clothes. During interviews with staff (S#2-S#7), (6) out (7) stated that they had not heard or observed facility staff not changing (R#1)’s clothes. Evaluation Report continues LIC 9099-C On 8/28/24, LPA Alfonso Iniguez conducted the following interviews: (7) out of (7) facility staff stated that (R#1) was assisted daily with changing clothes in the mornings and evenings. In addition, (7) out of (7) facility staff stated that there were times when R#1 refused to change clothing when facility staff asked to assist them initially in the morning, but facility staff would return after approximately 15 minutes and ask (R#1) again if they wanted to change and (R#1) will agree to change clothing the second time. Allegation: Resident's shower wall has a large hole The details of the complaint alleged that there is a hole on the shower wall in (R#1)’s room. On 8/29/24, during the facility's Health and Safety check, LPA Iniguez inspected (R#1)'s shower and found no signs of a large hole or crack, or any indication of recent repairs. In addition, LPA noticed that the shower on (R#1)’s room is a pre-fabricated shower made of a sturdy material, not easy to made a crack or hole on it. During an interview with the facility's maintenance director (S#9) on the same day, they mentioned that they had not noticed a large hole in (R#1)'s shower. They also stated that (R#1)'s POA reported a crack in the shower wall. (A#1) stated that once (R#1)’s POA reported there was a large hole in (R#1)’s shower. (A#1) stated that she went to investigate the hole in the shower wall, (A#1) observed a 4-inch crack in the shower wall and not a large hole. Immediately, (A#1) give the order to the maintenance crew to fix the crack and it was repaired the same day. On 10/25/22, LPM Lourdes Montoya conducted interviews at the facility and found the following: During an Interview with the Administrator (A#1), she stated that she had not observed a hole in (R#1)’s shower. During an interview with resident 1 (R#1), they stated that they had not observed a hole in their shower. During interviews with residents (R#2-R#10), (9) out of (10) stated that they had not observed a hole in their shower. During interviews with staff (S#2-S#7), (6) out of (7) stated that they had not observed a hole in (R#1)’s shower. Evaluation Report continues LIC 9099-C On 8/28/24, LPA Alfonso Iniguez conducted the following interviews: (7) out of (7) facility staff stated that they did not observe a hole in (R#1)’s shower. During this investigation, LPA found did not find sufficient evidence to support the above-mentioned allegations. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Heather Argueta /Administrator.