complaint·December 19, 2023

Continued from LIC9099 Interviews conducted with facility staff stated that first aid was applied after R1 sustained the cut lip. Based on information obtained these allegations are Unsubstantiated . A finding that the complaint is Unsubstantiated means that although the allegations may have happened there is not a preponderance of evidence to prove that the allegation occurred. Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents. Continued from LIC9099 During our investigation we learned four (4) of the nine (9) staff interviewed, and two (2) of the hospice staff interviewed (an RN and Home Health Aide), observed R1 to be left in soaked or soiled briefs, and found R1 to be lying on their back numerous times in a week. Please note hospice staff visited R1 at the facility twice or more a week. R1’s responsible parties were interviewed, and it was noted they also observed R1 in soiled briefs, and not repositioned. R1's care plan stated they were to be changed and repositioned every 2 hours. The facility indicated they had a log of dates/times with staff initials as to when R1 was changed and repositioned however they were not able to provide copies of these logs. It was reported by a visitor of R1 that they observed R1’s linens to be soiled and reported it to facility staff. The visitor visited the next day after reporting the soiled linens to staff and observed the soiled linens to have not been changed. Visitor stated that they were told by facility staff that changing R1’s linens was the Hospice agency’s responsibility. Interviews conducted with Hospice providers stated that there were multiple times that R1’s linens were found to be soiled. Review of R1’s Hospice Care Plan dated 07/19/2022, stated that Hospice is responsible for changing linens once per week. Review of R1’s Admissions Agreement dated 09/25/2021 stated that “fresh linen is provided weekly or as necessary.” Facility’s Program Plan states the following: “basic services for all residents in the facility include cleaning residents’ beds and linens weekly, or more often as needed.” Investigation findings revealed the facility did not ensure they followed R1’s Care Plan. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Exit interview conducted. Plan of Corrections reviewed and developed with Administrator. Copy of report, LIC9099-D, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.