complaint·December 13, 2023

Regarding Allegation #1 : Staff did not keep a resident’s room free from odor. This complaint alleged staff did not keep R1 room free from odor. LPA Calderon conducted an interview with A1. A1 states that R1 refuses to allow staff to clean R1 room or allow pest control to spray for fruit flies. A1 states that staff cleans R1 room and attempts to control the odor in R1 room. LPA Calderon conducted an interview with S1-S2. 2 out of 2 staff state that R1 refuses to allow staff to clean R1 room. 2 out of 2 staff state that when R1 is not in R1 room staff cleans R1 room. 2 out of 2 staff state that staff attempts to control the room odor but due to R1 urine it is hard to control odor in R1 room. LPA Calderon conducted an interview with R1-R4. 4 out of 4 residents were not capable of answering any questions due to health issues. On 12/13/2023 LPA Calderon toured the facility with A1. LPA Calderon noted R1 room had an odor of urine. LPA Calderon noted R1 in soiled pants while inside R1 room. Regarding Allegation #2 : Staff did not properly maintain a resident’s bed while in care. This complaint alleged staff did not maintain bed for R1. LPA Calderon conducted an interview with A1. A1 states that R1 does not allow staff to clean his bed or change R1 mattress sheets. LPA Calderon conducted an interview with S1-S2. 2 out of 2 staff state that R1 does not allow staff to clean R1 bed. 2 out of 2 staff state that when R1 is not inside R1 room staff changes R1 bed sheets. 2 out of 2 staff state that R1 does not allow staff to put plastic sheet on the bed to protect the mattress from R1 urine. On 12/13/2023 LPA Calderon toured the facility with A1. LPA Calderon noted that R1 bed had a urine spot. Appears R1 had urinated in the bed. LPA Calderon noted R1 bed mattress was soiled and ripped up and needs to be replaced. LPA Calderon noted that staff wanted to put clean sheets on R1 wet bed without addressing the urine spot in R1 mattress. Regarding Allegation #3 : Staff did not ensure a resident showered while in care. This complaint alleged staff did not make sure R1 showered or clean self. LPA Calderon conducted an interview with A1. A1 states that R1 refuses to take a shower or have staff help R1 to take a shower. LPA Calderon conducted an interview with S1-S2. 2 out of 2 staff state that R1 refuses to take a shower and staff cannot force R1 to take a bath or shower. 2 out of 2 staff state that R1 can take a shower by R1 self. LPA Calderon conducted an interview with R1 who was sitting in a wheelchair. R1 appeared confused and under the influence of alcohol. LPA Calderon noted that R1 had a vodka bottle on the side of R1 wheelchair and was taking drinks out of the bottle. LPA Calderon asked R1 to stop drinking prior to the interview. R1 states that R1 has not taken a shower for 3 days. 3 out of 3 residents were not able to give an interview regarding showering due to health issues. On 12/13/2023 LPA Calderon toured the facility with A1. LPA Calderon noted that R1 appeared to not be clean and was wearing soiled pants. LPA Calderon noted R2-R4 appeared to be clean and wearing clean clothes. LPA Calderon did not review any shower logs for R1 or any other resident. Reviewed capability assessment (date 2/13/2017) for R1, baths or showers without help, uses toilet by self. Reviewed physician report (date 1/18/2018) for R1, report notes health issues. Reviewed resident appraisal (date 2/3/2022) for R1, noted health issues for R1. Reviewed needs and service plan (dated 2/3/2022) for R1, noted health issues. Regarding Allegation #4 : Staff did report an incident involving a resident. This complaint alleged staff did not keep incident reports for R1. LPA Calderon conducted an interview with A1. A1 states that R1 has lived in the facility for the past 6 years. A1 states that no incident reports have been written up on R1 actions such as not showering and refusing to allow staff to clean R1 room. A1 states that S1 kept handwritten notes from 07/01/2023 to 12/01/2023 regarding R1 not allowing staff to clean R1 room, R1 refusal to take a bath or shower or clean R1 bed. LPA Calderon conducted an interview with S1-S2. 2 out of 2 staff state that they did not write any formal incident reports regarding R1 room, refusal to take a shower, change R1 bed or sheets. 2 out of 2 staff state that S1 kept some handwritten notes for R1 from 7/1/2023 to 12/01/2023 regarding R1 refusal to take a shower, clean R1 bed or room or control the odor in R1 room. LPA Calderon reviewed R1 facility notes and LPA Calderon could not find any incident reports for R1 regarding room odor, bed status, or showering. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the allegations of “staff did not keep a residents room free from odor”, “staff did not properly maintains a residents bed while in care”, “staff did not ensure a resident showered while in care”, “staff did not properly report an incident involving a resident “is found to be SUBSTANTIATED. According to the California Code of Regulations (Title 22, Division 6, Chapter 8) the following deficiency has been observed and citation issued (ref LIC9099D). A face-to-face meeting was conducted with Administrator Angelique Gradney and a hard copy was provided.