complaint·August 17, 2023

The investigation revealed the following: Allegations: Facility does not have sufficient night staff to meet the needs of the resident in care & Resident was left for an extended period of time soiled in urine and vomit. The details of these allegations stated that, since 10/07/22, there has been inadequate overnight caregiver coverage, which has led to several hours of a resident laying in bed soiled in urine and sometimes in vomit. Also, residents diapers and soiled beddings are not changed for up 6 hours during the overnight shift. Based on interviews conducted, the statements obtained were consistent and corroborated with the above-mentioned allegations. Interviews conducted confirmed that during the month of October 2022, Staff 2 (S2) was a “no-show” multiple times, leaving only one caregiver on duty during the overnight shift, between the hours of 10:30pm – 6:30am. Statements obtained confirmed that overnight staff were observed in the office area most of the time, sitting or sleeping and not doing rounds every two hours and checking on the residents. It was reported that overnight staff would at times ignore the residents call for help and when staff did respond, residents waited 2 or more hours before receiving assistance. Statements obtained from residents and staff corroborated that caregivers were not doing diaper changes during the overnight shift and/or changing soiled resident beddings and morning staff would often times find incontinent residents laying in bed, wet and soiled for hours. Based on the investigation conducted, there was sufficient evidence found, proving the above-mentioned allegations to be true. Based on LPA’s observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was provided to the Assistant Administrator along with the Appeals Rights. The investigation revealed the following; Allegation: Facility staff are not meeting resident's hygiene needs while in care. Based on interviews conducted, the statements obtained were inconsistent and did not corroborate with the above-mentioned allegation. Staff and residents interviewed stated that residents are given showers twice a week or as needed. Residents on hospice will normally receive three to four showers per week. Residents on hospice will receive showers twice by the hospice agency and once or twice by the facility staff, depending on resident needs. If a resident has an accident or requests an additional shower, staff will accommodate their request. Staff and residents interviewed denied staff not meeting residents hygiene needs. Residents interviewed did not present any concerns about not receiving or missing showers. Based on the investigation conducted, there is insufficient evidence to support the above-mentioned allegation to be true. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted and a copy of this report was provided to the Assistant Administrator.