complaint·April 6, 2023

Allegation: Staff do not respond to resident's call button in a timely manner . It is alleged that staff take over 30 minutes to 2 hours to respond to signal/call light requests made by residents, especially during night hours due to the facility being short staffed. According to staff interviews, the response time varies between 5 to 20 minutes depending on whether the call request is received during meal times. There are a total of 14 staff working at the facility, of which [10] staff are caregivers. There are 3 caregivers during the day shift, four (4) staff between 3 PM- 12 AM, and two (2) caregiver/med-techs during the night shift. Staff stated that resident (R1) did not want to purchase a signal call pendant. The call light system was tested and is operational. It is tested once a month by maintenance staff to ensure there are no faults. Staff indicated that caregivers use walkie-talkies to communicate and each caregiver is assigned specific residents. The Administrative Assistant/med-tech Staff (S1) is not assigned residents, but assists with caregiver responsibilities if other caregivers are busy with other residents. A total of seven (7) residents were interviewed. Four (4) out of seven (7) stated staff take a long time to respond to their calls, and sometimes have to yell for help, especially during night time hours. Allegation: Staff do not provide resident with nutritious meals. It is alleged that resident (R1's) nutritional health needs are not being met because the resident is often provided cup o noodles, sandwiches, or rice with soy sauce to meet it's vegetarian diet. Resident (R1's) has multiple medical diagnosis that require a special diet, and also has religious dietary restrictions. Staff interviews indicated that the facility offers regular food, an alternative menu, diabetic and low sodium diet food, but it does not have a separate vegetarian menu or low carbohydrate menu that meets R1's needs. Staff stated that the resident is accommodated and given rice, vegetables, noodles, or cultural TV dinners are purchased. Staff staff stated that R1's MD has been notified that family sends the resident unhealthy drinks and candy. In addition, staff reported that resident primarily requests quesadillas and pancakes, skips lunch meals, and does not adhere to it's physician ordered diabetic diet. Four (4) out of seven (7) residents interviewed stated they are not receiving nutritious meals i.e. very little vegetables and fruit, and at least twice a week they are served hot dogs or pizza. Based on resident (R1's) file documents i.e Physician's Reports and appraisals R1 requires a renal, diabetic, low salt, low carbohydrate diet, pureed diet, and vegetarian diet. The facility is not ensuring the resident obtains required food items to meet it's multiple medical diagnosis. Resident (R1) requires a renal diet and it is not on a facility renal diet. Additionally, on 3/20/2023 Administrator was unable to provide LPA kitchen staff food handling certificates, and the main cook's certificate was expired. Corporate staff (S4) stated that the facility has a Registered Dietician (RD) that evaluates food menus once a year. However, staff (S4) did not provide RD's contact information and could not recall whether R1's special dietary needs were evaluated by the Registered Dietician. The facility did not provide proof that an RD is contracted. Only a link to a general website "TELADOC" was provided. Allegation: Resident's bathroom is in disrepair. It is alleged that resident (R1's) bathtub/shower plumbing has had an intense leakage that needs repair for approximately 3 - 4 months. Staff were made aware and instructed R1 not to use it's room bathtub/shower and instructed both residents that share the bathroom to go downstairs to the 1st floor to bathe. Resident (R1) is ambulatory but often uses a wheelchair which has caused the resident a major inconvenience every time it bathes. A total of seven (7) residents were interviewed, of which five (5) residents confirmed that there have been plumbing issued, like no hot water in their bathrooms for a long time, since 2022. Staff acknowledged that rooms 28 and 29 have major plumbing issues since January 2023. The facility contacted the City of Monrovia so that they can shut off the water for repairs, but the project was postponed. No issues with water for cooking and other needs were reported. However, residents (R1 & R2) were no relocated to other vacant rooms in the facility, and as of today the plumbing problem has not been repaired in 2 rooms (B1 & B2) located outside the main building. The hot water had very low water temperature readings. Rooms 28 & 29 plumbing issues have been repaired. Allegation: Administrator is not communicating with Ombudsman. It is alleged that the Ombudsman has made multiple attempts to communicate with facility Administrator regarding resident concerns, but did not receive a return phone call or reply to emails sent. On 1/27/2023, 2/1/2023, 2/7/2023, 2/17/2023 (in person & via telephone call), and on 2/24/2023 (via email) attempts were made to communicate with facility Administrator. As of 3/10/2023, the Ombudsman had not received a response from the facility regarding the 2 facility visits, 2 telephone messages, and 1 email. Based on observation, record review, and interviews conducted the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . Deficiencies are being cited according to California Code of Regulations, Title 22. See LIC 9099D. Exit interview was conducted with Administrative Assistant Claudia Sanchez. A copy of the report and appeal rights were issued.