complaint·June 16, 2021

Allegation: "Facility staff failed to give resident medication as prescribed." Based on document review and interviews conducted the findings indicate resident (R1) was prescribed Furosemide [Lasix] tablet 20 mg medication. Per staff interviews, the medication was filled on time and administered as directed. Staff stated medication refills are ordered one (1) week before the medication ends. It was reported that resident (R1) is compliant with medications and never communicated medication issues with med-tech staff. A total of seven (7) residents were interviewed. Two residents stated they have not been medications as prescribed. One resident stated that on several occasions one medication that is to be taken once weekly was not administered. Another resident stated that during Summer 2020 staff failed to administer medications as prescribed. A total of eight (8) staff were interviewed. The facility has new Administration staff that stated they are unaware of medication issues/errors that allegedly occurred during June 2020- July 2020. All staff denied the allegation. On 5/14/2021 during the random medication review/audit a medication error was observed. During medication review resident (R8) was missing medication Furosemide 80 mg. The two med-tech staff (S9 & S10) that assisted during the medication review did not find the missing medication. Neither staff had an explanation or documentation to show the reason the medication was not available and/or discharged by a physician. At the end of visit dated 5/14/21 staff (S9) stated resident (R8's) hospice agency was contacted and it was confirmed the facility failed to request R8's medication refill on time. Allegation: "Facility staff failed to meet resident's hygiene needs." Based on records review and observation resident (R1) was scheduled to receive sponge baths due to non-ambulatory physical condition. The Pre-Placement Appraisal stated resident needs help with bathing. The Appraisal Needs and Services Plan did not include bathing assistance notes. However, R1 is wheelchair bound, unable to bathe on its own, and needs incontinence care. Three (3) residents reported not receiving bathing assistance regularly and as needed. Staff interviewed denied negligence in meeting resident's hygiene needs. One (1) staff stated R1 received sponge baths twice a week. Other staff interviewed stated they had no knowledge of R1's bathing schedule or whether the resident failed to get sponge baths per shower log schedule and as needed. See- LIC 9099C for report continuation. Continuation- Allegation "F acility staff failed to meet resident's hygiene needs." Full shower log records were requested. Only some shower log schedules were obtained. Current Administration staff stated they were unable to find old (2020) and recent (2021) shower log records. Per record review, resident (R1) requires incontinence care and bathing assistance. Resident (R1) stated staff provide a bed pan and tell the resident to stay in bed. Resident reported that incontinence care is provided in the morning and is provided incontinence care again until approximately 8pm -9pm. Resident (R1) requests incontinence assistance but often waits a long time because due to body size two-person staff assist is needed. Staff stated it takes approximately 30 minutes to provide incontinence care. Staff acknowledged there were staff shortages during Summer 2020. In addition, during Summer 2020 resident (R1) did not have in place a physician order for a Hoyer Lift. Allegation: "Facility staff does not respond timely to resident's requests for assistance or at all." Based on observations made during facility visit inspection dated 5/14/2021 there is evidence indicating staff do not respond to resident's requests for assistance. LPA conducted random testing of call signal system in resident rooms. A total of 11 rooms were inspected. Out of the 11 rooms five (5) rooms did not have operable call signal system in the room i.e. bathroom wall unit, or pendants accessible to non-ambulatory or bedridden residents. Some rooms did not have any signal system in the rooms, and/or did not have a call signal pendant accessible to them. Room 165 call signal system was tested at 1:15 pm, but staff responded to the pendant call until 1:47 pm. Staff were observed to be across the hall from room 165 during the call light system test and did not respond to the request for assistance. At the time of the visit the facility had a pager system of which only one (1) pager was observed to be operable. It is alleged that it takes hours for staff to respond to call signal system. Resident interviews revealed staff response time to assistance requests at times takes longer than 10 minutes or hours. Deficiencies are being cited based on LPA observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22, see LIC 9099D. An exit interview was conducted and Plans of Correction were reviewed and developed with Administration staff. A copy of the report and appeal rights were discussed and left with Operations Director Tyler Cheney.