complaint·December 16, 2024

Allegation: Staff did not adequately assist resident with incontinence care needs in a timely manner. On 11/6/24, LPA Shirley reviewed Appraisal Needs/Services and observed that it states R-1 is incontinent. During review of facility records, specifically incontinence log for R1, incontinence log is dated from 8/2/24 thru 11/4/24, with 4 months of changes entered on one sheet. The dates listed on the log are not consistent. A few dates are listed in order then the date skips to the next month without completing the prior month. On 11/6/2024 LPA observed pull cords in the residents’ rooms. There are pull cords in every apartment unit located in the living room, bedroom and bathrooms. During the interview with S-2 on 11/6/24, LPA was told that residents on the Assisted Living floors also wear call pendants around their necks. LPA was also told by S-2 that the alert resets when units button is pushed. Upon review of facilities pull cord logs, LPA Shirley observed that dates ranged from 8/1/24 thru 11/6/24. Log lists the time call button is pushed by resident as well as the times caregivers respond and reset the call button. Per the log, there were 51 alerts with response times over 30 minutes, 8 alerts with response times over an hour and on 8/3/2024 the log lists that a pull cord was pushed at 4:46am and was lasted for a duration of three hours, forty-seven minutes and eighteen seconds, which was the longest time of delayed response from caregivers. LPA Shirley interviewed staff-1 thru staff-7 (S-1 thru S-7). LPA asked if staff assist residents with incontinence needs in a timely manner. Of those interviewed, 6 out of 7 staff answered yes, and 1 answered no. LPA interviewed resident-1 thru resident-7 (R-1 thru R-7). LPA asked residents if staff assist them with incontinence needs in a Con'd on 9099-C timely manner. Of those interviewed, 2 out of 7 answered yes, 1 answered no and 4 do not need incontinence assistance. Based on interviews that were conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D.