Complaint·July 25, 2022

Regarding Allegation #1 : Staff do not follow COVID-19 protocol. On 03/01/2022 LPA Calderon interviewed W1 who states that staff did not wear masks and residents were not wearing mask. W1 states that staff did not follow covid-19 protocols and did not test guest coming into the facility. On 03/01/2022 LPA Calderon interviewed S1-S3 who all state that they wear mask every time they are inside the facility and test for covid-19 and take the temperature of any guest that come into the facility. Staff states that they follow all protocols regarding covid-19. On 03/01/2022 and 07/25/2022 LPA Calderon noted staff following covid-19 protocols while inside the facility. Regarding Allegation #2 : Staff do not assist resident with incontinence care. On 03/01/2022 LPA Calderon interviewed W1 who states that staff were not taking care of R1 incontinence care and were not changing the resident while sleeping in the bed. On 03/01/2022 LPA Calderon interviewed S1-S3 who state that R1 is well cared for and R1 diaper is changed when needed. Staff states that R1 incontinence care is taken care of by staff or by the hospital. On 07/25/2022 LPA Calderon reviewed medical records for R1 to include needs and service, physician report and Kaiser hospital records. All records state no issues with incontinence care for R1. On 07/25/2022 LPA Calderon reviewed medical records for R2-R4, no issues noted for incontinence care by staff. On 09/19/2022 LPA Calderon interviewed S1 who states that R1 does have a incontinence care plan from R1 doctor which staff follows. S1 states that R1 diapers are changed 4 to 6 times per day depending on R1 needs and the number of times R1 goes to the bathroom. S1 states that facility staff is trained for incontinence care needs of all residents in their care. Regarding Allegation #3 : Staff speak inappropriately to resident: On 03/01/2022 LPA Calderon interviewed W1 who states that staff yells at R1 and speaks to R1 inappropriately. On 03/01/2022 LPA Calderon interviewed S1-S3 who state no staff yells at residents and never speaks to residents inappropriately. On 07/25/2022 LPA Calderon reviewed records for R1-R4, there are no reports from residents or resident family of any staff speaking to residents in an inappropriate manor. On 03/01/2022 and 07/25/2022 LPA Calderon noted the interactions between staff and residents which there did not appear to be any issues. Regarding Allegation #4 : Facility does not meet residents’ nutritional needs. On 03/01/2022 LPA Calderon interviewed W1 who state that R1 is not being fed food and staff are not following doctors’ instructions regarding feeding R1. On 03/01/2022 LPA Calderon interviewed S1-S3 who state that they follow all physician instructions regarding feeding R1 and all residents in the facility. Staff state that R1 is diabetic, but there are no doctors’ instructions regarding the feeding R1. On 07/25/2022 LPA Calderon reviewed resident R1-R4 files and medical records and there is no physician report as to what to feed R1 or R2-R4 in their records. Records do support that R1 is diabetic. On 03/01/2022 and 07/25/2022 LPA Calderon noted staff feeding residents for breakfast and lunch. Regarding Allegation #5 : Staff did not seek medical care for resident. On 03/01/2022 LPA Calderon interviewed W1 who states that staff refused to take resident to the hospital when needed. On 03/01/2022 LPA Calderon interviewed S1-S3 who state that W1 and W1 family did not allow staff to call 911 or take R1 to the hospital. Staff states that they called R1 family and was advised by W1 not to call 911 or transport R1 to the hospital. Staff states they follow all DSS regulations and call 911 when needed and make sure that all residents medical needs are taken care of. On 07/25/2022 LPA Calderon reviewed R2-R4 medical files and there is no report regarding 911 calls or residents being taken to the hospital. R1 records do show R1 being taken to the hospital on 01/03/2022, but no other hospital records are found. Regarding Allegation #6 : Staff did not inform responsible party of residents change in condition. On 03/01/2022 LPA Calderon interviewed W1 who states that staff did not call W1 or W1 family regarding any medical changes to R1 or R1 being taken to the hospital. On 03/01/2022 LPA Calderon interviewed S1-S3 who state that they did call W1 regarding any medical change to R1 and S1-S3 all state that W1 did not want facility staff to call 911 or take R1 to the hospital. Staff states that they always call resident’s family informed or any medical change to R1. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the allegation of Staff do not follow covid-19 protocol, staff do not assist resident with incontinence care, staff speak inappropriately to resident, facility does not meet residents nutritional needs, staff did not seek medical care for resident, staff did not inform responsible party of residents change in condition is found to be UNSUBSTANTIATED. An exit interview was conducted and copy of the Complaint Report was provided to the Administrator (Krystal Adams).