complaint·August 3, 2022

Regarding the allegation: Staff failed to change resident’s clothes It was alleged that staff, are not changing the resident’s clothes. Interview with Resident #1 (R1) revealed that they would be left in the same clothes for extended periods of time, but R1 did not specify the time frame. Information obtained from interviews with responsible parties who had been in the facility, claimed that R1 was observed to be in the same clothes when they would visit but could not confirm if it was clean or not. During the 3/1/2022 visit, R1 was in the process of moving and appeared to be in clean clothes. Further interviews claimed that residents are being changed daily. Staff #2 (S2) stated that Resident #2 (R2) refuses to wear additional clothes but sometimes is unable to persuade R1 to wear something different. During today’s visit residents appeared well groomed and in clean clothes. Based on interviews which were conducted, there is insufficient evidence to support the allegation that staff failed to change the resident’s clothes. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated at this time. Regarding the allegation: Staff failed to reposition resident It was alleged that resident is not being turned regularly. Interviews with staff revealed that facility staff reposition residents that require repositioning as needed and every two hours. Interviews with staff revealed that all facility staff are trained in repositioning. Interviews with facility staff revealed that staff were able to move/reposition R1 who required to be taken to the bathroom for showers and occasional toileting. Interviews with residents confirmed that staff are repositioning them as needed and every two hours. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time. Regarding the allegation: Staff failed to provide comfortable accommodations for the resident It was alleged that staff, failed to provide comfortable accommodations for the resident. The complainant alleged that R1 reported that a space heater was left in their room making it extremely hot. Interviews with R1 denied allegations that a space heater was ever left however an overhead central heating system would occasionally be turned on by a senile resident. R1 confirmed that if the temperature would get uncomfortable that staff would adjust it. Further interviews confirmed that facility temperature is comfortable and remains comfortable throughout the day and night. During today's complaint visit, the LPA observed the facility to have the thermostat set a comfortable temperature of 75 degrees Fahrenheit. Based on the investigation, there is insufficient evidence to support the claim that staff failed to provide comfortable accommodations for the resident. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Staff fell asleep in resident’s room It was alleged that staff fell asleep in the resident’s room while on shift. Interview with Resident #1 (R1) revealed that Staff #1 (S1) had fallen asleep more than once in their room on a couch located in the room, while conducting routine care checks. Information obtained from interviews with responsible parties who had been in the facility, confirmed claims that staff were observed sleeping in common spaces. S1 confirmed that they sleep at the facility on a couch in the living room or rests in the daytime on a bed outside. Additional staff interviews confirmed that staff do sleep in the living room couch during the night shift. During the 3/1/2022 visit, the LPA’s did not observe a designated staff room. The LPA discussed personal accommodations relating to staff and residents with Staff Irina Fried. Based on the investigation, there is sufficient evidence to support the claim that staff fell asleep in resident’s room. This allegation is deemed Substantiated at this time. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit (See 9099-D). Exit interview conducted. A copy of the report was provided.