Complaint·February 15, 2022

The Department reviewed R1’s admission agreement. In the section change in care services under assessment/service plan indicates the Terraces of Roseville will perform an assessment of your needs annually or as needed and will invite you and your family to participate (at least annually) in selecting and designing an appropriate care program from you. In the section change in services, indicate if the Terraces of Roseville determines, through the assessment, that you require additional services or a different care program than the one in which you are participating, you agree to the additional services or care program appropriate to your needs. The rate for the new service or care program shall apply immediately. The Community will give you written notice of a care change and any corresponding rate increase within (2) business days after providing newly assessed services. The Department conducted interviews and received statements from a total of three (3) facility staff. Interview with Resident Care Director (RCD), Kristina Wardlow, indicated assessments is conducted on new residents, residents with change of condition, and residents who return from a Skilled Nursing Facility. RCD listens to residents’ complaints and concerns regarding medical needs and care needs and incorporate that in their assessment if necessary. According to RCD, resident’s responsible party will be notified when there is a change in the level of care assessment because it changes how much they pay. If resident can make their own decision, then RCD wouldn’t inform family members because resident can manage on their own. This agency has investigated the above listed allegations. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred therefore, we have found the allegation(s) to be UNSUBSTANTIATED . An exit interview conducted. Interview statement received from Complainant indicated, care staff (S1) left R1 in shower unassisted resulting in R1 sustaining a fall. The facility submitted an initial record of incident to CCL for review. In the report it indicated, on 1/22/2021 R1 had an unwitnessed fall and R1’s POA/family and Physician were notified of the incident. R1 was transferred to the hospital for further evaluation. The Department had reviewed R1’s Physician’s report. The Physician’s report indicated R1 is not able to bathe self, dress/groom self, and care for own toileting needs. Shower schedules, call logs, and staff schedule/ timecard was requested from the facility for review. The facility was unable to provide CCL call log documents for review. R1’s showers were scheduled for Monday and Thursday between 7 PM and 8 PM. R1 was unable to provide names of the care staff that was assisting R1 during the night of the incident. The Department reviewed employees’ timecards and was able to determine which care staff was working the night of the incident. According to the ED, most of the care staff that worked the night of the incident is no longer working at the facility. The Department had conducted a search on Guardian to obtain care staff’s contact information. The Department was unable to gather interview statements from care staff that was working the night of the incident. Allegation: Facility did not notify responsible party of change in resident's condition. – Unsubstantiated. According to Complainant, on two different occasions, two (2) nurses conducted assessments via interviews with R1. During the first interview, the nurse reduced the number of services from two to one. One month later, the other nurse reported similarly. Reducing from two to one impacted CalPERS’ reimbursements. Complainant stated the facility has a policy that family members are contacted when residents request changes in their services. Level of care assessments indicated that R1’s Responsible Party or family members were notified of the change in services. On 09/12/2019, an initial level of care assessment was conducted, indicating that R1 requires assistance with bathing from one person twice a week. On 10/06/2020, an assessment was completed due to change in services, which indicated that R1 requires assistance with bathing from one (1) person once a week. On 01/27/2021, another level of care assessment was conducted due to change in condition, increasing bathing assistance from once a week to twice a week. According to the level of care assessments, it indicated that R1’s daughter was notified of the changes.