complaint·January 30, 2025

The investigation revealed: Allegation: Staff do not respond to resident's call for assistance in a timely manner. It is alleged that facility staff take too long after pendant is push for assistance. LPA Interviewed five (5) staff and four (4) of five (5) staff denied the allegations. One staff stated that when staff arrived for their shift one day, R1 was soiled and not assisted in timely manner. LPA interviewed five (5) residents and two (2) of five (5) residents stated that facility staff sometimes take a long time to assist them. LPA reviewed call light log, and, on at least 4 different occasions, it did take over 60 minutes for staff to assist residents during the month of December 2024. There is enough evidence to substantiate this allegation. Allegation: Staff do not ensure that resident's toileting needs are met. It is alleged that resident was left in his bodily fluids after bowel and bladder movement and developed a rash due to staff neglect. LPA interviewed five (5) staff and four (4) of five (5) staff denied the allegations. LPA interviewed five (5) residents and four (4) of five (5) residents were not able to corroborate the allegation. One staff stated that when staff arrived for their shift one day, R1 was soiled and not assisted in timely manner. Some staff stated R1 had rash when R1 arrived to facility. There is enough evidence to substantiate this allegation. Based on interviews and information obtained the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . Deficiency is being cited according to California Code of Regulations, Title 22, Division 6, Health and Safety Code, Chapter 3.2, Article 02. See LIC 9099D. The Investigation revealed: Allegation: Resident sustained a pressure ulcer due to staff neglect. It is alleged that resident developed a pressure ulcer due to neglect of facility. LPA interviewed five (5) staff and five (5) of five staff denied the allegation. LPA interviewed five (5) residents and four (4) of five (5) residents cold not corroborate the allegation. R1 was admitted to facility on 11/27/2024 with ulcer on right foot and admitted to Home Health agency on 11/29/2024 to provide wound care. Documentation shows R1 had pressure ulcer(s) as far back as 11/18/2024 while residing at SNF. R1 was admitted to Hospice on 12/23/2024 and documents from Hospice show R1 had stage 2 and stage 3 ulcers. R1 has history of skin breakdown when admitted. Facility addressed the issue right away by ordering wound care for resident through home health agency. There is not enough evidence to support this allegation. Allegation: Staff do not follow resident's special diet. It is alleged that resident was on special diet and facility did not honor it by feeding R1 pasta, pastries, pizza and food that R1 is not supposed to eat. LPA interviewed five (5) staff and five (5) of five staff denied the allegation. LPA interviewed five (5) residents and four (4) of (5) residents were not able to corroborate the allegation. LPA reviewed doctor’s orders for R1 and it showed that R1 was regular diet with no dietary restrictions. Other special needs were documented as no salt added (NAS) thin liquid. Two (2) residents stated that the food does not have salt and that they must add salt to their taste. Staff stated that food is cooked with NAS as many residents cannot have salt in their diets. Based upon records review, and interviews conducted, the findings indicate that, although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted with Maria Roleda, Clinical Supervisor. A copy of the report was provided. .