complaint·February 6, 2023

***This report supersedes the report LIC9099C dated 12/29/22.*** During a subsequent visit dated 12/29/22, LPA obtained/reviewed a copy of the Staff/Resident rosters and Resident #1's (R1) records, interviewed Staff #2 to Staff #6 in the library and interviewed Resident #2 to Resident #5 in the library. In regards to the allegation: Facility has a scabies outbreak. Based on complaints received on 11/24/20 (Control #28-AS-20201124163559) and on 12/15/20 (Control #28-AS-20201215092514) Residents were diagnosed with scabies within the time frame of this complaint and interviews with staff revealed they were never trained on how to handle residents with scabies. Both complaint investigation findings were substantiated. In regards to the allegation: Staff did not notify resident's authorized representative of incidents. Interviews with Staff indicate the authorized representative is notified if there is an incident with the Residents. Based on allegation details, R#1 had an un-witnessed fall on 09/08/20. Hospice notes indicate the hospice agency notified the authorized representative of the incident but there are no records that indicate the facility notified R#1's authorized representative. Based on the department's record review, evidence and interviews, in the investigation revealed: The preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview conducted with Laura Hernandez and a copy of this report and appeal rights provided. ***This report supersedes the report LIC9099C dated 12/29/22.*** During a subsequent visit dated 12/29/22, LPA obtained/reviewed a copy of the Staff/Resident rosters and Resident #1's (R1) records, interviewed Staff #2 to Staff #6 in the library and interviewed Resident #2 to Resident #5 in the library. In regards to the allegation: Resident fell while in care. Interviews with 6 of 6 Staff indicated they do not recall whether R1 had a fall while residing in the facility. Records indicate R1 had an un-witnessed fall on 09/08/20 while under Hospice care. Per Hospice notes, R1 denied pain and plan of care to continue. In regards to the allegation: Resident sustained bruises while in care. Review of R1's medical records indicate R1 has a medical condition resulting in progressive movement which caused R1 to be susceptible to bruising. Interviews with Staff and review of the Individual Services Plan indicate preventable measure were put in place to prevent R1 from bruising due to the medical condition. In regards to the allegation: Staff tied resident to the bed. Interviews with 5 of 5 Staff indicate they have never tied a Resident to the bed. Interviews with 4 of 4 Residents indicated they have never been tied to a bed. In regards to the allegation: Staff not meeting resident's hygiene needs. Interviews with indicated Residents are meeting the Resident's hygiene needs. Interviews with 4 of 4 Residents indicate their hygiene needs are being met. Based on LPA's interviews and record review, the investigation revealed: Although the allegations may have happened or is 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 conducted with Laura Hernandez and copy of this report provided.