complaint·August 28, 2024

Allegation: Staff are not meeting resident's hygiene needs It was alleged that R1 is not getting showers and their hair is greasy and dirty. Moreover, it was reported that R1’s shoes, saturated with diarrhea, were found in the cabinet with R1’s toothbrush. To investigate this allegation, LPA Ruiz conducted an interview with the Executive Director and was informed that Tradition 1 has five (5) staff and Tradition 2 has four (4) staff and a weekly schedule with their assignments are being provided to all staff. Additionally, two (2) staff interviewed confirmed that they receive their assignment, and each staff member is assigned to provide care and supervision to no more than 8 residents and all residents are scheduled to have showers at least twice a week or as needed. Although basic services have been provided to R1 (regarding the showers and diaper change), the facility staff failed to clean R1’s shoes, saturated with diarrhea, which was found in the cabinet with R1’s toothbrush (picture attached). Based on LPAs observation and a picture evidence this allegation is Substantiated. Resident's room is malodorous During the initial visit conducted by LPA Ruiz on 05/13/22 a physical tour was made with the Executive Director. Upon entry into the Memory Care Unit (Traditions 1) LPA and the Executive Director smelled a strong odor of urine. Moreover, when LPA and the Executive Director toured R1’s room #122B they observed that the toilet was clogged, and the room was malodorous. Interview with the Executive Director revealed that she was not aware of the issue. A maintenance order had been placed immediately. Based on LPAs observation, this allegation is deemed Substantiated. Staff are not providing adequate laundry service to resident During the physical plant tour, conducted by LPA Ruiz on 05/13/22, the laundry machines were in working order and laundry services were being provided. However, interviews with the Executive Director and a Memory Care Director revealed that there were having trouble with soap. Staff had reported that soap for laundry was an issue. The facility had already reached out to Eco Lab and complaint of soap leaving stains. Based on interviews and picture evidence this allegation is Substantiated. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are cited and noted on LIC9099-D. Exit interview conducted, appeal rights explained and copy of this report signed and delivered. Allegation: Staff left resident in soiled diapers for extended period of time It was alleged that R1 was left in saturated diapers with feces and urine in bed. During the initial visit, conducted by LPA Ruiz, interview with the Executive Director, Memory Care Director and staff were made. At that time, LPA was informed that R1 was diagnosed with Dementia and wore adult diapers due to urinary incontinence. Two (2) staff interviewed denied that R1 was left in soiled diapers for an extended period of time. S1 stated that R1's diaper was constantly changed throughout the day and that R1 was given a bath two (2) times per week. LPA was also informed that all incontinent residents are scheduled to be changed every two hours or as needed. In addition, during today’s visit, LPAs conducted an interview with six (6) out ot ten (10) residents and all residents interviewed expressed no concerns regarding the above allegation. Lastly, during the interviews and physical plant tour, LPAs observed all residents looked clean and well taken care of. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is Unsubstantiated at this time. Allegation: Staff are not providing adequate food service to resident's It was alleged that facility staff failed to provide adequate food service by serving residents food that they can't cut. To investigate this allegation, LPAs conducted an interview with the Culinary Executive Chef and two (2) staff members. All parties interviewed informed LPAs that the facility provides three (3) nutritious meals and snacks in between. Moreover, the Executive Chef informed LPAs that the kitchen area has a board with residents pictures/names that require special diet and the facility always follows doctors orders. In addition, LPAs were informed that protein (chicken, meat, fish) is always being chopped prior to be served to all residents. Two (2) staff interviewed corroborated the Chef's statement and informed LPAs that they always assist Memory Care Unit residents with cutting their meals upon request. Lastly, interview with six (6) out of ten (10) residents expressed no concerns of the food services. Based on the information obtained, there was insufficient evidence to corroborate the allegation of staff not providing an adequate food service to residents. Therefore, the allegation is deemed Unsubstantiated at this time. Continue on LIC9099-C Allegation: Staff are not safeguarding resident's personal belongings. It was alleged that R1's clothes had gone missing. To investigate this allegation, LPA Ruiz conducted an interview with the Executive Director, Memory Care Director and staff, during the initial visit. All parties interviewed denied the above allegation. LPA Ruiz was informed that due to R1's diagnoses, R1 would misplace his/her personal belongings. Nothing has been brought up as missing. LPA was also informed that once the management makes aware of this type of an issue, all staff gets notified and the facility starts a search. Most of the time (95%) the residents misplace their belongings and the staff finds and returns it to them. Six (6) out of ten (10) residents interviewed, during today's visit, expressed no concerns regarding the above allegation. Based on the information obtained this allegation is deemed Unsubstantiated at this time. Allegation: Resident was severely dehydrated To investigate this allegation, LPA Ruiz, conducted an interview with the Executive Director and staff during the initial visit. All parties interviewed revealed that they always keep juice and water next to R1’s bed and that R1 was drinking fluids regularly. A review of medical records from the hospital did not reveal any information to verify that at the time of admission to the hospital (in January 2022) R1 was dehydrated. Based on interviews and record reviews, this allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of this report signed and delivered.