complaint·August 25, 2023

Regarding allegation: Residents in care have access to centrally store medications. It is alleged that resident's creams and ointments are being left in resident rooms, accessible to them. At 8:30AM, during the tour of the physical plant, LPA observed resident medication baskets filled with medications, left on top of the kitchen counter, along with other food items, while R3 was walking around the facility. LPA asked S2 why the medication was left out. S2 responded that due to deep cleaning of the kitchen cabinets, the medication was taken out and would be put back once completed. Staff continued to leave the medication out and unattended while S3 passed by several times sweeping and mopping the home. Shortly after, S1 arrived at the facility and sat at the kitchen counter in front of medication while speaking with S2, and the medication was still not put back. During the tour of resident bedrooms, LPA did not observe any medications, special creams, and/or ointments left accessible in their rooms. Per staff training records, training on Centrally Stored Medications was successfully completed on January, February March and August of 2023. Per interviews conducted with staff, (2) of (3) staff state that deep cleaning of the cabinets happens every other day and medications are usually left out that way. This allegation is Substantiated. Regarding allegation: Staff are unable to communicate with residents in care. It is alleged that residents are having trouble with speaking to care staff due to a language barrier and not understanding English well, causing issues to arise. During the interview conducted with S3, LPA Maldonado had to rephrase the questions being asked several times due to S2 speaking little English and not fully understanding the questions. During interviews conducted with staff, (3) of (3) denied the allegation and stated they had no issues communicating with residents due to language barriers. Per interviews conducted with residents, R2 corroborated the allegation, stating that it is hard to communicate with S2 because S2 does not understand much English. R2 stated that many times, R2 has to ask the same questions for S2 to understand what R2 is asking- however R2's needs are still being met. This allegation is Substantiated. Based on LPA's observations and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is SUBSTANTIATED. Per California Code of Regulations, Title 22, deficiencies were observed and will be cited on the LIC9099-D. An exit interview was conducted with Administrator Elizah Arganosa and a copy of the report and appeal rights were provided. The investigation revealed the following: Regarding allegation: Resident sustained pressure injuries while in care due to lack of care and supervision. It is alleged that R3 was taken to the hospital due to bed sores. Per review of incident report dated 7/25/23, 911 was called on 7/20/23 due to R3 passing out, as R3 was eating less and drinking less fluids. At the time of the incident, R3 was being provided physical therapy and regular nurse checks by Home Health. Per interview with R1, R3 returned back to the facility on Hospice due to R3's declining health, with admission date of 8/03/23 and hospice care plan requires R3 to be repositioned every two hours. Per interviews conducted with staff, (3) of (3) staff stated that all bedridden residents are repositioned every (2) hours. Per hospice notes, on 8/11/23, 8/15/23 and 8/21/23, R3 did not receive any wound care. On 8/25/23, R3 was treated for four (4) stage 2 ulcers on the sacral/buttocks area. LPA attempted to interview R3, but was unable to due to R3's cognitive impairment. This allegation is Unsubstantiated. Regarding allegation: Staff do not ensure facility is kept clean. It is alleged that the facility is unclean and staff do not clean resident rooms regularly. Per interviews conducted with R1-R5, (3) of (5) residents denied the allegation and stated that staff clean daily by sweeping, moping, dusting, and washing resident personal items. Upon arrival, LPA observed S2 sweeping and moping the common areas and resident rooms, and S3 was cleaning the kitchen cabinets and dining room area. LPA inspected resident rooms and resident bathroom. They appeared to be clean, sanitary, organized, and free of hazards. (3) of (3) staff stated the facility is cleaned regularly on a daily basis and deep cleaning of the kitchen is done every other day. This allegation is unsubstantiated. Regarding allegation: Staff do not provide proper incontinence care to residents in care. It is alleged that R1 was neglected by staff and acquired a diaper rash while in care. Per staff interviews, (3) of (3) staff stated that residents who require incontinence care are checked on and changed every 2 hours or more frequently, if needed. LPA was unable to interview R1 due to R1 being in the hospital. LPA attempted to interview R1 telephonically at the hospital, however, LPA was informed by hospital staff that R1 is no longer there. (3) of (5) resident's interviewed denied the allegation and stated that staff assist them with changing and frequently check them for changing needs. This allegation is unsubstantiated. Regarding allegation: Residents are not provided proper food service. It is alleged that the facility is not serving residents healthy meals. During today's visit, LPA observed the facility food supplies and obtained a copy of the facility menu and resident's dietary restrictions. LPA observed a sufficient amount of food that meets Title 22 Regulation requirements of 2-day perishables and 7-day non-perishables for the amount of residents in care. (Report Continued on LIC9099-C...) There was a variety of nutritious foods available such as fresh fruits, vegetables, proteins, milk, and juices. The menu posted on the refrigerator reflected a variety of nutritious meals to be served and the resident's dietary restrictions was posted next to it to remind staff of resident's requirements/needs during meals. (3) of (5) residents interviewed denied the allegation and stated that they have no complaints about the food service. They are provided options when they ask and are given 3 meals a day with snacks in between. (3) of (3) staff interviewed stated they follow resident's special diets, provide them with 3 meals per day, give them options if they desire something different, and provide snacks between meals. This allegation is unsubstantiated. Regarding allegation: Residents are not provided proper medication assistance. It is alleged that staff are making medication errors. LPA reviewed resident medications and the MARs. It was determined that (6) of (6) residents medications are being administered as described and documented properly. (3) of (5) residents interviewed stated that staff assist them with administering their medications. (3) of (3) staff interviewed stated medications are given to residents daily as prescribed and denied any medication errors occurring. Per staff training certification, it was discovered that all staff have received proper medication administration training and resident's personal rights on medication refusal/acceptance. This allegation is Unsubstantiated. Regarding allegation: Objects that pose a risk to residents are accessible to residents in care. It is alleged that residents that there are harmful objects in residents rooms with dementia and psychosis. LPA Maldonado inspected resident rooms and did not observe any hazardous items accessible to residents in care. (3) of (5) residents denied the allegation and stated that all hazardous objects/materials are locked in different cabinets in the facility. (3) of (3) staff stated that all hazardous/toxic items including medications and ointments are kept locked and inaccessible to residents in care. LPA observed all sharps, medications, special ointments, and cleaning supplies/toxins to be stored in a locked drawer in the kitchen, in the garage which remains locked, and in a locked cabinet in the hallway- all inaccessible to residents in care. This allegation is unsubstantiated. Regarding allegation: Staff do not ensure resident's personal items are safeguarded. It is alleged that care staff are asking for things/money from residents. (3) of (5) residents denied the allegation and stated that staff are very professional and caring. R3 stated to have offered S2 a bracelet one time as a thank-you, however S2 did not accept it. (3) of (3) staff denied the allegation and stated staff are trained to not accept anything from residents for the care being provided. This allegation is Unsubstantiated. (Report continued on LIC9099-C...) Regarding allegation: Staff are not meeting residents need by abandoning their shift. It is alleged that care staff are abandoning their posts. Per interviews conducted (3) of (3) staff denied the allegation and stated that residents are never left unsupervised and their care needs are being met. Per S1, there are no issues with staffing, nor have there been at any time. Per the staff roster, there are currently (7) staff working at the facility, some on-call. Per S1, if any staff call off, they can call their on-call staff to cover shifts if needed. (3) of (5) residents interviewed, the allegation was denied and staff are always present at the facility to provided assistance and supervision. This allegation is Unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegations are UNSUBSTANTIATED. Per California Code of Regulations, Title 22, no deficiencies were observed or cited. An exit interview was conducted with Assistant Administrator Elizah Arganosa, and a copy of this report was provided.