complaint·December 11, 2023

CONTINUED FROM FORM LIC9099 Regarding the allegation that Staff violated resident's personal rights , the following has been concluded: Based on records and evidence reviewed, observation conducted at the facility and interviews conducted, it is determined that on multiple occasions, facility staff passively or actively disregarded the resident's expressed wishes and either continued providing care without taking the request into account or acknowledging it. Resident R1's physician report on file along with multiple appraisals indicate that R1 does not have dementia and is able to express their needs and wishes, which were then ignored by facility staff. As a result, the allegation is found to be Substantiated, meaning that the preponderance of evidence standard has been met. A Type A deficiency is cited on the attached form LIC9099-D. Regarding the allegation that Staff isolated resident while in care , the following has been concluded: Based on interviews conducted and evidence reviewed, it was confirmed that on multiple instances, facility staff locked the door to R1's unit in the evening despite requests made verbally to leave the door unlocked. As a result, the allegation is found to be Substantiated, meaning that the preponderance of evidence standard has been met. A Type A deficiency is cited on the attached form LIC9099-D. Regarding the allegation that Facility is in disrepair , the following has been concluded: Based on facility visit and interviews conducted, it was determined that following a technical incident, the facility's call system was left non-operational during an entire week-end, with no alternative means of contacting staff to request assistance or care being provided. At the time of the initial visit, visual alerts were observed to be operating, but sound alerts and doorbell rings were still not working. Therefore the allegation is Substantiated, meaning that the preponderance of evidence standard has been met. A Type B deficiency is cited on the attached form LIC9099-D. Regarding the allegation that Facility is unsanitary , the following has been concluded: Based on evidence submitted and interviews conducted, facility staff was noted to not be observing basic infection prevention measures and were confirmed to be handling food or drinks with the same gloves that they had conducted toileting and handling of incontinence items with, thus not meeting the standards of sanitation required by Title 22 regulations. The allegation is thus found to be Substantiated, meaning that the preponderance of evidence standard has been met. A Type B deficiency is cited on the attached form LIC9099-D. An exit interview was conducted and a copy of this report along with appeal rights were provided to a facility representative. CONTINUED FROM FORM LIC9099-A Regarding the allegation that Resident doesn't feel safe at facility , the following has been concluded: Based on interviews conducted, records reviews and tour of the facility's physical plant, no items of non-compliance putting the resident's safety into jeopardy could be identified. After a suspicion of electrical issues was expressed by R1's family, facility maintenance staff along with Fire Marshall staff inspected the facility without finding any dysfunction needing to be addressed. As a result, the allegation is found to be Unsubstantiated, meaning although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Regarding the allegation that Staff left resident unattended in feces for an extended period , the following has been concluded: According to video evidence obtained during the investigation, there was at least one instance of having diarrhea during which R1 expressed difficulty in obtaining assistance. The evidence provided did not sufficiently establish the exact time frame during which the resident was left unattended that night beyond the four minutes captured by video. As a result, the allegation is found to be Unsubstantiated, meaning although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Regarding the allegation that Staff did not treat resident with dignity and respect , the following has been concluded: Based on the review of records and interviews conducted, a consistent pattern of not allowing the resident with the dignity and respect required by facility staff could not be evidenced. As a result, the allegation is found to be Unsubstantiated, meaning although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Regarding the allegation that Staff did not meet resident's needs , the following has been concluded: Facility staff states that they notified R1's conservator and relatives that the resident had reached a level of care incompatible with their remaining at the facility, however due to the duration of the resident's admission at the facility, facility staff eventually agreed to let the resident remain admitted there and to provide the required care and supervision there. Despite indications that care for R1 was complex, there is insufficient evidence to demonstrate that the facility did not meet the resident's needs before their relocation to a different board and care. Thus, the allegation is found to be Unsubstantiated, meaning although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to a facility representative.