complaint·May 27, 2022

6 of 7 staff never observed any bruises on R1. 1 Staff (S1) noted in an incident report dated 10/12/2020 that R1 had a bruise on R1’s upper left thigh, and R1 was complaining that it hurt. The report stated that S1 worked the previous night and S1 did not notice the bruise and R1 was not hurting. On 10/29/2020 R1 met with medical doctor and had an x-ray of R1’s pelvis. The findings indicated no fractures. Facility staff did not seek medical treatment for resident in care: Administrator said resident R2 has had a sore near R2's left ear prior to being placed at the facility. Sometime in mid to late September, caregiver notified Administrator that the sore near R2’s left ear was slightly bigger and red. Administrator scheduled an appointment with medical doctor on 9/15/2020 to have R2’s ear checked. Administrator said the sore on R2’s ear was due to skin cancer. Primary care physician was first notified by facility staff member about R2’s ear wound during visit on 9/15/2020. Primary care physician had prior visits with R2 in August and September and did not previously notice the wound. R2’s family member (F2) first noticed the wound 2-3 weeks prior to 12/8/2020. F2 believed, R2 got the wound from picking at R2’s face. Staff are not ensuring residents getting their daily nutrition: Administrator and 7 staff were interviewed and stated that staff always provide meals, fluids and encourage residents to eat and drink fluids. Care Logs reviewed for August -October 2020 note staff monitoring residents’ food and water intake. S1 stated that meals are prepared fresh. Meals include fresh fruit, proteins, and vegetables. Groceries are purchased monthly and fresh produce weekly or as needed. S5 stated that R1 sometimes did not want to eat. At times staff would assist R1 but R1 could eat on their own if they chose to. 3 of 6 residents stated that there are getting enough food and liquids. 3 of 6 resident were not able to respond to interview questions. Menus reviewed for 10/2020 and noted a selection of fruits, proteins and vegetables were included. Other menu options are provided. Staff try to prepare food items preferred by each resident. On 10/27/2020 LPA observed 6 Residents were having lunch in the dining room. A variety of foods to include hot dogs wrapped in a crescent roll (Pigs in the Blanket), fries, watermelon and peanut butter brownie with whipped cream. Page 2 of 4 Unusual Incident reports are not documented Administrator denies not reporting incidents. Administrator stated that each incident is reviewed to determine if an incident report needs to be completed. A resident will be checked for signs of injury and pain. An incident that occurred in mid-September i nvolving R1 was not written as R1 was not observed by staff to have any skin tears or bruising. S1 stated that staff note incidents, complete reports and forward to the Administrator for review. S2 notes incidents in the care logs and reports those to the Administrator but does not generate formal reports. S3 stated the administrator is responsible for all reporting. Records review of Care Logs and Incident Reports were reviewed for the period of 8/1/2020 through 10/31/2020. Resident monitoring for change in condition and incidents were recorded in the care logs. Incident Reports involving injury or complaint of pain were generated and submitted to the Department. Staff not helping residents with incontinence needs Administrator denies residents incontinent needs are not being met. Administrator stated that staff are continually checking on residents to see if they need assistance with toileting or incontinence needs. The overnight staff do rooms checks every two hours. The room checks are not logged. 4 of 4 staff deny residents toileting or incontinent needs are not met. S1 stated that staff check on the residents frequently during the am, before and after meals. S3 stated that staff are aware of those residents that need additional monitoring and more frequent checks. 3 of 6 residents do not have issues with care provided. Records review of Care Log for the period of 8/1/2020 through 10/31/2020 notes instances were room checks were completed to document additional monitoring of residents. Staff made inappropriate comments to residents Administrator and 4 staff were not aware or did not have direct knowledge of staff making inappropriate comments were made to residents. 3 of 3 residents did not have any concerns regarding care or staff. Review of facility records, Incident reports and Care Logs, resident files did not note any incidents of inappropriate comments by staff to residents. Page 3 of 4 The Department has investigation the above complaint allegations. Based on information from interviews conducted and records reviewed, although the allegations listed above 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. No Deficiencies cited under California Code of Regulations Title 22 Report reviewed with Angelique Robinson Administrator and a copy of this report provided. Page 4 of 4 The Department investigation the above complain allegation. Based on interviews and records review, there is preponderance of evidence to prove the alleged violations did occur, therefore the allegation is SUBSTANTIATED. See 9099-D for deficiencies cited per the California Code of Regulations, Title 22. Immediate Civil Penalty being assessed in the amount of $500.00. Report reviewed with Angelique Robinson Administrator and a copy of this report and appeal rights provided. Page 2 of 2