complaint·January 6, 2025

The investigation revealed the following: Regarding the allegation “Staff do not secure residents medications”, it is being alleged that staff do not secure medications (for example, medications refused by residents or not consumed by residents) where it is not accessible to residents in care. Interviews conducted revealed the following: 4 out of 4 resident interviews were inconclusive. 2 out 4 witnesses agreed with the allegation. 3 out of 5 staff who work on the Third Floor denied with the allegation. Observations revealed the following: On 12/17/2025, the department toured the Third Floor and did not observe medications. On 1/6/2025, the department toured the Third Floor and did not observe medications. Regarding the allegation, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was left with the Executive Director. The investigation revealed the following: Regarding the allegation “Staff do not ensure that residents incontinence needs are met”, it is being alleged that there is a lack of incontinence care for residents in care, especially during nighttime; for example, not checking residents every two hours and/or leaving residents in soiled undergarments and clothing for extended periods of time. Interviews conducted revealed the following: 4 out of 4 resident interviews were inconclusive. 2 out 3 caregivers who work on the Third Floor denied with the allegation. 4 out of 4 witnesses agreed with the allegation. Records reviewed of “Resident Incident Details Report” of Pull Cords on the Third Floor from Rooms 301 to 308 dating from October 2024 to December 2024 revealed the following: · There was 1 incident when the “Duration” took over 3 hours. · There were 3 incidents when the “Duration” took over 2 hours. · There were 9 incidents when the “Duration” took over 1 hour. · There were 2 incidents when the “Duration” took over 50 minutes. · There was 1 incident when the “Duration” took over 40 minutes. · There were 5 incidents when the “Duration” took over 30 minutes. · There were 11 incidents when the “Duration” took over 20 minutes. 13 out of 32 incidents occurred at nighttime from 6 PM to 12 AM. 3 out of the 6 residents of the “Resident Incident Details Report” require incontinence care according to their “Task Administration Record.” * The “Duration” of alert indicates the time staff took to respond and “Reset Device” (reset pull cord device) in residents’ room. The “Duration” (alert) is only turned off when the device is reset. * According to the Executive Director, the response time of staff should be 9 minutes or less. Records reviewed of “Task Administration Record” for the Third Floor of Residents who Require Incontinence Care for the Month of October 2024 & November 2024 revealed the following: 3 out 7 resident “Task Administration Record” for the Month of October 2024 and November 2024 under incontinence care are left blank; staff did not initial on date nor time. Therefore, there is no documented evidence that 3 out 7 residents were provided with incontinence care. 7 out 7 resident “Task Administration Record” for the Month of October 2024 and November 2024 under incontinence care are mostly left blank; staff did not initial on date nor time. Therefore, there is minimal documented evidence that incontinence care was provided to residents in care as required according to their "Task Administration Record." Records reviewed of “Task Administration Record” for Resident 1’s Incontinence Care for the Month of October 2024 & November 2024 state the following: “#14 Continence – Assist w/ Toileting / Changing” “As Needed” missing initials from 10/1/2024 to 10/30/2024 and 11/1/2024 to 11/31/2024. The document states the following: “Instructions: Staff will need to assist resident every 1-2 hours to bathroom or as needed . Resident’s Needs/Preferences: Requires for toileting and is taken to and from bathroom; needs assistance with putting on and changing incontinence supplies, hygiene and/or changing linen…Service Provider Responsibilities: Staff will assist resident every 2 hours each shift or as needed to soil of clothing, hygiene.” Therefore, there is no documented evidence that incontinence care was provided to Resident 1 from 10/1/2024 to 11/1/2024. Regarding the allegation “Staff do not ensure that residents incontinence needs are met”, the preponderance of the evidence standard has been met therefore the allegation is substantiated. Regarding the allegation “Staff do not answer residents call buttons in a timely manner”, it is being alleged that staff members take over twenty minutes to answer residents call buttons (pull cords). Records reviewed of “Resident Incident Details Report” of Pull Cords on the Third Floor from Rooms 301 to 308 dating from October 2024 to December 2024 revealed the following: · There was 1 incident when the “Duration” took over 3 hours. · There were 3 incidents when the “Duration” took over 2 hours. · There were 9 incidents when the “Duration” took over 1 hour. · There were 2 incidents when the “Duration” took over 50 minutes. · There was 1 incident when the “Duration” took over 40 minutes. · There were 5 incidents when the “Duration” took over 30 minutes. · There were 11 incidents when the “Duration” took over 20 minutes. There were 32 incidents where it took staff over 20 minutes to respond to a residents pull cord. * The “Duration” of alert indicates the time staff took to respond and “Reset Device” (reset pull cord device) in residents’ room. The “Duration” (alert) is only turned off when the device is reset. * Interviews conducted revealed the following: According to the Executive Director the response time of staff should be 9 minutes or less. Observations revealed the following: The department observed pull cords in resident bedrooms and resident bathrooms. Regarding the allegation “Staff do not answer residents call buttons in a timely manner”, the preponderance of the evidence standard has been met therefore the allegation is substantiated. Deficiencies are being cited based on records reviewed and interviews conducted in accordance with the California Code of Regulations, Title 22. Deficiencies regarding incontinence care and staff response time. A civil penalty is being assessed due to it being a repeat violation, regarding incontinence care. An exit interview was conducted, and a copy of this report was left with the Executive Director along with their appeal rights.