Inspector’s narrative
What the inspector wrote
Department has learned that resident’s R1 LIC 602s (physician’s assessment) dated 9/11/2020 & 6/16/2022 states dementia, sundowning & wandering behavior, sleep apnea, able to communicate needs, and able with assistance to do the following bathe self, dress/groom, feed, care for own toileting needs. In addition, care plans 12/15/21 states “requires stand by assistance with s/set up and performance of grooming tasks (28 points); 3 to 4x/week showers (10 points); requires stand by assistance with dressing and undressing 2x/day (31 points)” and care plan 6/13/2022 states “requires stand by assistance with s/set up and performance of grooming tasks (28 points); 1 to 2x/week showers (13 points); requires hands on assistance with dressing and undressing 2x/day (37 points). Department has learned that picture taken by POA on July 19, 2022 shows resident R1 with an extremely red groin rash and stated that resident R1 was being found with same clothes when visiting consecutive days. Facility staff stated, “that resident was refusing showers” and has no shower or changing record logs. In regard to staff not assisting resident with hygiene needs, at this time Department can’t prove or disprove that it has occurred.
In regard to, “Facility staff did not ensure resident's bathroom was sanitary.” Department has learned that facility has the following number of staff in memory care per shift AM 4 care staff & 1 med tech, PM 4 care staff & 1 med tech, and NOC 2 care staff & 1 med tech. According with MC Director Juan Ferrel interview “There is a person designated for housekeeping in Memory Care” which are not caregivers. “Care staff do the bed, light cleaning, and pick up clothes on the floor, make sure that bathrooms are clean. If bathrooms are not clean, they contact housekeeping. Housekeeping change sheets on beds onn the housekeeping days assigned for the room. In the case of an accident care staff will change sheets and placed them to wash. Care staff still does the laundry for residents.” During visit to facility on 8/3/2022, LPA toured the facility and randomly observed bedrooms/bathrooms and found facility clean. There is not sufficient evidence for the Department to prove or disprove that residents bathrooms were not sanitary.
Continued LIC 9099-C
Department investigated allegation “Facility failed to follow admission agreement”, resident R1 admissions agreement signed on 10/ 2020 states that “b. (pg 9) Amount of Refund - within thirty (30) days after your apartment has been vacated and your property has been removed from it, Oakmont shall pay you or your responsible party a refund of any prorated unused portion of your final monthly fee payment…”. According with records reviewed and interviews, facility provided a refund to resident R1/POA on August 17, 2022. Amount refund was based on care plan, care fees, and rent fees. Based on records reviewed and interviews, Department can not prove or disprove that facility didn’t follow admission agreement at this time.
A finding that the complaint allegations of “Facility staff did not assist resident with hygiene needs.”; “Facility staff did not ensure resident's bathroom was sanitary.”;
“Facility failed to follow admission agreement.” are unsubstantiated meaning that 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.
No deficiencies cited during this inspection.
Department has learned that resident R1 was admitted under assisted living in October 2020, however; moved into memory care on July 2021. LIC 602s (physician’s assessment) for resident R1 dated – 9/11/2020 & 6/16/2022 states dementia, sundowning & wandering behavior, sleep apnea, able to communicate needs, and able with assistance to do the following bathe self, dress/groom, feed, care for own toileting needs. In addition, care plans provided by facility states the following:
• Care plan 12/14/20 states requires set up and/or assistance with clothes 1x/day (15 points); breathing treatments – resident requires staff observation and assistance 1 to 2 times per day (8 points) Det up CPAP machine. Machine in night stand and hose in closet. Ensure it is plugged in, nose piece attached to hose and plastic container is filled with water – observe/report breathing treatments. Maintain safe/clean environment.
• Care plan 12/15/21 states requires stand by assistance with s/set up and performance of grooming tasks (28 points); 3 to 4x/week showers (10 points); requires stand by assistance with dressing and undressing 2x/day (31 points); requires a fall management program due to fallen within the past year (16 points); breathing treatments – resident requires staff observation and assistance 1 to 2 times per day (15 points); status checks – resident doesn’t require status checks (0 points)
• Care plan 6/13/2022 states requires stand by assistance with s/set up and performance of grooming tasks (28 points); 1 to 2x/week showers (13 points); requires hands on assistance with dressing and undressing 2x/day (37 points); requires a fall management program due to fallen within the past year (16 points); breathing treatments – resident requires staff observation and assistance 1 to 2 times per day (15 points); status checks – resident doesn’t require status checks (0 points)
According to facility “Instructions” on care plans specified above, Breathing Treatments for care plans 12/15/21 & 6/13/22 – states “Resident requires staff observation and assistance 1 to 2 times per day.” With the following instructions “Assist resident with setting up CPAP machine in the evening around 8:30 – 9pm. This includes filling the cage with water, hooking the hose up, and turning it on.
Continued LIC 9099-C
Remove from apartment and clean during the day – store in med room. Resident ‘R1’ has tendency to hide pieces if left in apartment. The PM shift will bring to ‘resident R1’ around bedtime and assist with set up. Overnight shift will need to check in and see that ‘R1’ is still wearing it during the night.” – CPAP discontinued on 6/23/2022 by doctor’s orders.
Furthermore, CPAP discontinued order dated 6/23/22 from resident’s R1 doctor however, POA for resident R1 states that they were never contacted regarding requesting doctor to discontinue this order. Facility only communicated the decision after the fact – emails between facility and family members states family members questioning decision made by facility to fax doctor to discontinue CPAP orders. According to family and POA the doctor that prescribed CPAP was a pulmonologist who had also diagnosed R1 with COPD and sleep apnea. Email from Kathleen O. Acting ED to family members on June 22, 2022 at 4:02 PM state “…we established is that for the next 7 days we will have a companion with ‘R1’ from 8pm-8am. At that time that person will be observing her to see her sleep patterns and to redirect her with her Cpap.” However; facility staff on June 22, 2022 at 5:30 PM faxed R1’s doctor stating “Could you please review the Cpap treatment and possibly “discontinue” or write an alternative treatment?” Family and POA was never informed that doctor had been contacted to discontinue CPAP order. Family wasn’t informed until 6/24/22 that doctor had agreed to discontinue the CPAP.
MARs (Medication Administration Records) show that July there wasn’t an order for CPAP and June 2022 was done until 6/24/22. Facility states that “they are not to help with CPAP and has no policy or procedure for that.” Between June 3rd and June 21st of 2022 resident 14 times did not receive the treatment due to missing parts of the machine in addition of 2 times that resident refused. Doctor’s order for 2/14/2022 and 1/7/2022 states that “breathing machine at bedtime; ensure it is plugged in, nose piece attached to hose and plastic container filled with water and to be kept in medroom.” Based on documentation reviewed, facility failed to follow doctor’s orders and care plan as it was agreed upon and monthly charged.
Continued LIC 9099-C
Moreover, Resident R1 had a fall in an apartment for another resident on 7/22/2022 – per facility interviews around 11:30 PM – per sensor alarm record log resident’s R1 sensor went of on 7/22/22 at 9:01 PM, 9:09 PM, and 10:44 PM. Facility stated that resident R1 was found at resident’s R2 apartment around 11:30 PM on 7/22/22 – Resident’s R2 sensor alarm went off on 7/22/22 at 8:11 PM, 8:29 PM, 9:15 PM, 9:33 PM, and 9:50 PM according with record log provided by the facility. ED stated that “Since Nov/Dec of 2021, the system has been on 24/7” According with care plan 12/15/2021 & 6/13/2022, facility was aware that “Resident wakes up on some nights but is easily redirected back to bed after ADL needs are met”, “Resident wanders only within the common areas of the secured community”, and “Resident has fallen within the past year and requires a fall management program”; however, facility staff failed to respond when motion sensor went off and resident R1 wandered into another residents room and had a fall.
According with complaint allegations “Facility is not following resident's care plan.”; “Facility staff did not respond to resident's alarm.”; and “Facility staff did not dispense resident's medication as prescribed.” there were related observations made during visit. Based on LPAs' observations and interviews which were conducted and documentation reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.
Appeal of Rights Given.
The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
