complaint·February 10, 2023

Allegation 2: Facility did not provide incontinent care to resident. It is alleged R1 was only allowed 3 diapers per day. On 11/22/2022 LPA interviewed Licensee and Administrator regarding this allegation. Licensee stated that their policy is to check the residents’ diapers, in the morning, noon, night, and when needed not just 3 times a day. The administrator stated they do not change diapers and have been left alone in the facility to provide care for the residents, but no resident had needed a diaper change while she was at the facility alone. On 10/18/2022 LPA review of facilities Program states nonverbatim facility may retain a resident with manageable incontinence and the condition will be managed by the following, ensuring that the appropriately skilled professional develops the bowel and/or bladder program, if necessary, provides training to facility staff responsible for implementation of the program. R1’s records revealed an initial appraisal was not completed before R1’s admission to the facility and an incontinent care plan was not created for R1. The administrator stated there was no professionally developed incontinence care plan on file for R1. Based on the information obtained this allegation is deemed Substantiated. Allegation 4: Facility forced resident to sign up for hospice. Regarding the allegation the facility made the patient enroll in hospice. On 10/18/2022 an interview with the administrator regarding the allegation, revealed administrator and R1’s responsible party discussed acquiring "diapers" for R1. Administrator provided copies of text messages sent to R1's responsible party where the administrator states they called a hospice provider and later provided responsible party with two Hospice provider options. R1 was requesting an agency that provided physical therapy as per resident's Skilled Nursing Facility(SNF) Post Discharge Plan of Care. Review of SNF Discharge records revealed verbatim, patient will be referred to home-based palliative care. Interview with R1 revealed R1 did not believe themselves to be terminally ill and primary physician was not consulted when Hospice certification was made. Records of physician's certification for hospice benefits and physician's report revealed to have been completed by a physician other than R1's primary doctor four days after admission to the facility on 09/19/2023. R1 was admitted to facility on 09/15/2023. Based on the information obtained this allegation is deemed Substantiated. Deficiencies issued per CA code of Regulations Title 22. Appeal rights issued. Report signed and delivered. Exit interview conducted. Allegation #2: Insufficient staff to meet resident’s needs. Regarding the allegation it is alleged there was only one caregiver to assist 6 residents including R1. On 10/18/2022 the LPA was able to tour the facility and speak with three (3) out of the four (4) residents in care. LPA was also able to interview the administrator regarding the allegation. According to the Administrator, she has found it difficult to hire staff or retain staff. There are days when she has to be a caregiver or the Licensee has to stay all night as a caregiver. According to the Administrator there is usually two staff in the facility. Administrator has three full-time staff and one is on call. Residents stated that they receive immediate assistance when they call staff and they are happy with the care they receive at the facility. Based on the information obtained this allegation is deemed Unsubstantiated. No deficiencies issued, this report was signed and delivered. Exit interview conducted.