Complaint·February 7, 2024

Allegation: Staff are not meeting resident's needs. It is alleged that facility staff are not meeting the needs of resident (R1) because staff are not addressing changes in condition that are causing the resident to have constipation and/or diarrhea, incontinence issues, and self use of over the counter medications. A total of 11 residents were interviewed. One (1) out of 11 residents stated that staff do not meet their care needs. Resident (R1) stated their needs are met and confirmed they require medication management. All staff denied the allegation. However, based on document review the findings indicate that staff are not following facility medication management procedures and physician's orders because R1's Physician's Reports indicate the resident is not able to administer their own medications. LPA observed multiple bins in the tables that contained over the counter medications like Omeprazole, Mylanta, Pepto Bismol, foot creams, Alka Seltzer, that are not part of physician's orders, and there was Mylanta spilled on the side dresser and floor. In addition, R1 has a diabetic wound on the bottom of the foot that requires care. The dressing covering was very dirty and appeared to have not been changed in over 1 week. LPA took pictures of the foot dressing and showed the photos to staff who acknowledged the foot dressing should have been changed. Based on record review and observations, there is sufficient evidence to corroborate the allegation. Based on interviews conducted and document review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . Deficiencies are being cited according to California Code of Regulations, Title 22. See LIC 9099D. An exit interview was conducted with Liyon O'Quinn. A copy of the report and appeal rights were issued. Allegation: Staff did not safeguard resident's personal belongings. It was reported that resident (R1) has had their cell phone, tablet, and new clothes stolen by caregiver staff (S4). It was reported that the resident had knives that were removed from the room. According to interviews conducted, the findings indicate that resident (R1) has mental health conditions with periods of confusion and forgetfulness. All staff denied the allegation and stated that they just learned about the alleged missing cell phone yesterday. Staff (S4) denies stealing R1's phone, tablet, and clothing items. It was stated that the resident has asked S4 for assistance in finding the phone in the room. According to S4, the cell phone has been missing for months, and not 3 weeks. Staff (S4) stated that the resident orders many items and keeps cardboard boxes in the room, which are then removed with R1's permission. In regard to the knives that were removed by staff, it was stated that two large knives were removed and returned to a family member because they pose a threat to the resident. All staff deny the allegation. Resident (R1) stated that S4 has not stolen their cell phone. All other residents interviewed also denied the allegation. Resident (R1's) room was inspected and it was observed the resident has an operable land line telephone in their room, but no cell phone was observed. There is insufficient evidence to prove theft and loss of property. Allegation: Staff are harassing resident. It is alleged that the Director of Resident Services/Staff (S1) has been harassing resident (R1) about bad hygiene, "peeing" on the bed, bowel incontinence on pants/shorts when going to the dining room, and saying the resident is a horrible person that needs to move out." A total of six (6) staff were interviewed, of which all denied harassment of residents or knowledge that S1 has harassed resident (R1). Staff (S1) stated that they addressed hygiene to resident (R1) by trying to encourage the resident to take a shower and comb their hair, but it has always been done in private and in the resident's room. Staff (S1) denied ever asking R1 about bowel movement on their pants, mentioning any stains on R1's pants, or stating to R1 and family that the resident is horrible. Resident (R1) was the only resident that stated S1 harasses the resident. All other residents interviewed stated that staff (S1) treats the residents with respect and is accommodating to residents. Based upon record review and interviews conducted the findings indicate that, 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, therefore the allegations are Unsubstantiated. Exit interview was conducted with Liyon O’Quinn. A copy of the report was issued.