Complaint·January 26, 2024

CONTINUED FROM FORM LIC9099-A Regarding the allegation of an Illegal Eviction, the following has been concluded: Based on records reviewed and interviews conducted, a 30-notice to vacate served by the facility administrator was found to fulfil the regulatory requirements of Title 22 regulations by licensing staff. However, it was also determined that resident R1 was not evicted, but voluntarily moved to a more adequate facility with the assistance of a care coordinated agency. No eviction actually took place. As a result, the allegation is found to be Unfounded, meaning that meaning that the allegation is false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was provided to a facility representative. CONTINUED FROM FORM LIC9099-A Regarding the allegation that Staff do not ensure resident is kept in clean dry clothing at all times, the following has been concluded: The allegation is identical to the allegation that Staff do not ensure adequate incontinence care is provided to resident in care which was Substantiated and for which a type A citation was issued. In order not to cite the facility twice for the same deficiency, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. Regarding the allegation that Staff handled resident in a rough manner, the following has been concluded: Based on interviews conducted, multiple statements regarding potential rough handling of resident R1 by a facility former staff member were made. However, multiple contradictory statements were also made and no injury was evidence. There is therefore insufficient evidence to prove that the incident did occur, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. Regarding the allegation that Staff did not safeguard residents personal property, the following has been concluded: Several personal items belonging to R1 were reported as missing such as cosmetic products. Records reviewed indicated that the items in question had not been placed under the facility's safeguarding responsibility inventoried upon admission. Additionally, multiple lost items were later found in the resident's bedroom, and safeguarding solutions in the form of a lockbox were put into place. As a result, there is insufficient evidence to indicate that the facility was deficient, The allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of this report was provided to a facility representative. CONTINUED FROM FORM LIC9099 Regarding the allegation that Staff do not ensure adequate incontinence care is provided to resident in care, the following has been concluded: Based on interviews conducted and records reviewed, the facility does not provide routine care between the hours of 10pm and 6:30am, with the exception of non-routine, urgent needs being noted. It was however determined that it was a routine occurrence for facility staff to try to prevent R1's incontinence issues with the simultaneous use of multiple diapers at once rather than proceed to routine diapers changes throughout the night. Facility staff admitted to the practice which was also reported by hospital staff upon the resident's admission to the emergency department. The occurrence of a urinary tract infection can also be related to the practice. As a result, the allegation is found to be Substantiated, meaning that the preponderance of evidence standard has been met. A type A citation is issued in regard to the deficiency. Regarding the allegation that Staff did not ensure adequate care and supervision was provided to resident in care, the following has been concluded: Based on staff interviews, it was determined that after notifying a resident's responsible party that the facility was no longer suited to address the resident's need for nightly assistance, no modification to the resident's actually delivered care were made, thus not adequately meeting the resident's needs at the time. The allegation is therefore found to be Substantiated, meaning that the preponderance of evidence standard has been met. A type A citation is issued in regard to the deficiency. An exit interview was conducted and a copy of this report along with appeal rights were provided to a facility representative.