complaint·December 18, 2024

Allegation: Staff mishandled the residents' medications. It is alleged that night shift staff (S1) placed resident (R1's) PRN Lorazepam bubble pack in their backpack. According to information obtained, the Lorazepam's physician order was effective January 2024- June 2024. When R1's family was moving out the resident it was discovered that the PRN bubble pack medication could not be found. House Manager was informed the medication was missing. Manager allegedly had R1's PRN medication on top of their office desk, and stated that the medication had just been received. It is unknown why another bubble pack was ordered if R1 had only been administered 3 PRN pills during January 2024- June 2024. Two (2) out of 8 staff interviewed stated they saw a medication bubble pack that resembled the resident(s) bubble packs in staff (S1's) backpack. Facility Manager was notified of incident. Staff (S1) denied the allegation and stated that when R1 lived at the facility no other residents required night PRN medications. Staff interviewed stated that medications are counted every morning and are to be locked and centrally stored. Out of the six staff that denied the allegation, two staff stated they are not responsible for counting medications and cannot be sure if S1 took R1's medication and placed it inside their backpack. Staff were shown a picture of the alleged backpack that showed a bubble pack sticking out of the bag. Staff stated they do not know which staff the backpack belonged to, but acknowledged that the medication bubble pack should not have been readily accessible to residents in care. Staff were shown the photo depicting an unlocked medication bubble pack. Based on record review and photographic evidence there is sufficient evidence to corroborate the allegation because medications shall be kept kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. Allegation: Staff did not provide adequate care and supervision to a resident. It is alleged that staff showed negligence in caring for resident (R1) because the resident fell twice out of their chair while sitting in the dining room table. Additionally, it was reported that another resident (R4) was hospitalized in May 2024 due to a fall incident. Based on five (5) out of eight (8) staff interviews, the findings indicate that resident (R1) did fall while sitting in the dining room chair, and resident (R4) also sustained 2 falls, one was while sitting on the dining room chair, and the other was in their room where she sustained a large cut on the forearm. According to staff interviews, when resident (R1) fell in the dining area there were staff in the living room area next to the dining area, and R4's fall in their bedroom was not witnessed. Staff protocol is to check on residents every 1-2 hours when they are in their bedrooms and maintain constant supervision when they are in the living and dining room area. Based on record review, the facility did not submit to DSS Community Care Licensing fall incident reports pertaining to R1 & R4's falls. There is sufficient evidence to support the allegation. Allegation: Staff did not properly report an incident involving the residents. It is alleged that facility Administration staff did not notify residents responsible parties and Public Health about suspected scabies cases in the home. Resident (R1) and other residents received prophylaxis treatment for scabies. Facility manager stated that there was a resident that had a chronic skin disease that looked like scabies, but a biopsy did not confirm scabies. Facility Manager confirmed the suspected cases were not reported to public health or CCLD. All responsible parties interviewed stated they had no knowledge nor were notified that their loved ones were treated for suspected scabies. Per staff interviews, hospice agency staff recommended all residents be treated with Permethrin cream. All staff interviewed confirmed that residents received prophylaxis Permethrin treatment because they did not know if the rashes observed were scabies. Based on record review, the facility did not communicate to responsible parties the reason for the prophylaxis Permethrin treatment. A home health staff stated they developed a rash and were also treated for scabies. Resident (R1) fell twice while sitting in the dining chair, and resident (R4) fell twice, once while in their room, and in May 2024 while sitting in the dining room chair. The aforementioned fall incidents were not reported to CCLD. Additionally, no incident reports were submitted to DSS Community Care Licensing as required. Therefore, there is sufficient evidence to support the allegation that facility failed to properly report the suspected scabies cases. Based on interviews conducted, record review, and photographic evidence the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are cited in LIC 9099D. An exit interview was conducted and a copy of this report and appeal rights was provided to Facility Manager Belen Taico. Allegation: Staff physically abused a resident. The report states that on December 6, 2023, staff (S1) left bruising on Dementia resident (R1’s) both arms and left wrist that showed fingerprints. It is alleged that House Manager told family that former staff (S9) was the suspected perpetrator in effort to cover up for night shift staff (S1). A total of 8 staff were interviewed, of which 6 out 8 staff denied the allegation. Staff (S1) denied the allegation and stated one time they observed bruising on R1’s wrist, and staff it was likely due to mishandling of resident by other shift staff. Staff interviews revealed that R1 bruised easily due to very thin skin and combative illness behavior that included kicking, pulling of hair, and banging on full bed rails. Two (2) resident representatives of other residents residing in the home, and home health aide were interviewed, none reported observation or knowledge of alleged physical abuse. Therefore, there is insufficient evidence to corroborate the allegation. Allegation: Resident sustained unexplained injuries while in care. It was reported that on 8 dates [Dec. 6, 2023, Jan. 24, 2024, Feb. 14, 2024, Mar. 27, 2024, May 22, 2024, Jun. 20, 2024, and Jun. 26, 2024] Dementia resident (R1) had bruises on legs/thighs and arms, cuts and scrapes on knees, wrist area bruising, a sore on left leg, and bruise on right shoulder/arm area. It is alleged night shift caregiver (S1) caused the injuries because the staff works alone during the night shift and is known to be inpatient and abrasive in handling the residents. It was also reported that a now deceased resident (R2) was observed with scratches on their face, and the cognitively impaired resident stated that “the lady at night” scratched and hit the resident. Based on eight (8) staff interviews, none of the staff reported observing any staff mishandling the residents. Staff stated that due to cognitive impairment some of the residents often get combative during incontinence changes and feeding time. Staff stated that R1 often hit themselves on the bed rail or in the dining room table when the resident experienced aggression and anxiety. Staff stated they try to calm residents by giving them time and addressing the behavior incident a little later. None of the 3 rd party persons interviewed had knowledge of allegation. Record review revealed that R1 has physician orders for 2 antipsychotic medications that are used to manage behavioral symptoms like agitation and aggression in dementia residents. Therefore, there is insufficient evidence to support the allegation. Allegation: Staff verbally abused the residents. It is alleged that staff (S1) was overheard cussing at resident (R2) and on a different date the staff person was heard telling R2 “don’t be a pig when the resident was eating at the dining table. According to information obtained, S1 addressed R2 & R3 in a demeaning manner by saying that the residents are pigs and gross, and by yelling at resident (R4) when the resident requested more cookies. It was reported that night shift staff were verbally abusive because they treated residents R2 & R4 in a mean way. Resident (R1) referred to staff (S1) as “bad”. Based on 8 staff interviews, 2 out of 8 staff confirmed the allegation by stating that night shift caregiver staff (S1) is known to treat the residents impatiently and in a demeaning manner. Staff (S1) denied the allegation and stated they do not yell at residents. Other staff denied the allegation and stated that all staff treat the residents with respect. Responsible parties and 3 rd party agencies had no knowledge of verbal abuse or mistreatment. Two (2) residents with limited verbal ability were interviewed. One (1) resident reported no verbal abuse, and the other resident stated that night shift S1 is “half nice and half not nice”. Therefore, there is insufficient evidence to corroborate the allegation. Allegation: Staff did not meet a resident's diabetic needs. It is alleged that Facility Manager did not order necessary blood sugar strips to check resident (R1’s) sugar levels, and as a result staff did not check the resident’s blood sugar levels for approximately 5 days. Resident (R1) wore a diabetic sensor on their arm, and there is always supposed to be back-up glucose strips for the glucose meter in case the diabetic sensor is removed from the arm. The complaint alleges that on June 2, 2024, it was discovered that R1 had been without glucose testing strips since the last week of May 2024. A total of 8 staff were interviewed, of which 2 reported that the facility had insulin medication, but did not have glucose strips that measure sugar levels. According to staff interviews, R1 often pulled off the sensor monitor and/or it fell off, and the facility did not have another arm monitor. Therefore, protocol was to prick R1's finger and measure the glucose level on the glucose strip. The arm sensor is to be replaced approximately once a month. Six (6) out of 8 staff denied the allegation by stating that the facility did have glucose strips, but R1's family requested staff use a different brand type to be used. Staff interviews revealed that the facility did have diabetic lancet strips that were smaller in size because the house glucose monitor is smaller in size. According to staff interviews, R1's family thought that the house supply of strips were not reading the sugar levels correctly. House Manager stated they had no knowledge of any caregiver staff purchasing glucose strips in order to measure R1's glucose level. None of the 3rd party persons interviewed had knowledge of allegation. There is insufficient evidence to support the allegation. Allegation: Staff did not meet a resident's incontinence needs. It is alleged that in December 2023, a nighttime caregiver (S10) did not provide incontinence changes to residents in care and when a visitor entered the home it smelled like urine and feces. As a result, two other staff had to bathe the residents that morning, and threw away comforters, sheets, and bedding because they were heavily soiled. It is alleged that S10 stopped working at the facility and then in May 2024 was hired back, but the staff failed to provide incontinence care again and they were fired the following day. Based on staff interviews, it was stated that staff are supposed to check on residents every 2-3 hours and change their diapers as needed. Staff stated that during daytime hours they are checked frequently and changed right away, and during nighttime they are supposed to be checked at 9:30 PM, 12:00 AM, 3:00 AM, 5:00 AM, and then they are awakened at 6:30 AM and changed again if needed. Staff stated that sometimes the residents refuse incontinence assistance, but staff make further attempts, and they get changed. All staff denied the allegation. Responsible parties interviewed had no knowledge of incontinence care negligence. There is insufficient evidence to corroborate the allegation. Allegation: Staff did not prevent the residents from obtaining scabies while in care. It is alleged that multiple residents were treated for scabies between December 2023 – through mid-June 2024, but House Manager told caregivers that residents had eczema, and all residents were being bathe and provided incontinence care in one bathroom, despite the facility having another bathroom. As a result, resident (R1) contracted scabies. Based on record review and staff and hospice agency staff interviews the findings indicate that there were multiple residents experiencing skin conditions i.e. dry skin, general itchiness, and rashes on bilateral extremities, and as a precaution hospice agency staff ordered prophylaxis Permethrin treatment for all the residents. Based on hospice agency interviews, the findings indicate that the rashes the residents had did not improve with the Permethrin treatment. They improved with Benadryl lotion and pill, which indicates that it was most likely an allergic reaction. There is insufficient evidence to corroborate the allegation. Allegation: Staff did not isolate residents with scabies . According to information obtained staff did not isolate any of the residents that were suspected to have scabies between December 2023- June 2024, because the residents were still being allowed to congregate together in the living room and dining room areas where they spend most of their day in. A total of 8 staff were interviewed, of which 7 stated they had no knowledge of confirmed scabies cases, but if there are residents with confirmed scabies, they are to be isolated and their medical providers and/or hospice nurses would be notified. One (1) staff reported that House Manager did not isolate the residents even when they were being treated for suspected scabies because they wanted all the residents in the living room area to better supervise them. Facility staff provided written documentation from hospice agencies, and hospice staff were interviewed regarding suspected scabies cases. None of the hospice agency staff stated there were confirmed cases. They stated that as a precautionary measure all the residents showing rash like symptoms received prophylaxis Permethrin cream treatment. Staff confirmed that the residents received the treatment as recommended per medical professionals. None of the staff interviewed reported having had confirmed scabies. Therefore, there is insufficient evidence to prove the allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated . Exit interview conducted with Facility Manager Belen Taico. A copy of the report was issued.