complaint·April 17, 2024

Allegation: Facility is not providing adequate food services. Facility provided their menu for the week of 4/14/24-4/20/24. The facility provides a variety of food options for residents in care. Facility also provides an always available menu for residents, which also offers low sodium and vegetarian/vegan options upon request. LPA toured the kitchen area, and the facility has the required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. LPA observed kitchen staff preparing salads. LPA observed the food order invoices and the facility orders fresh produce almost daily. Facility orders all other food supplies approximately three times per week. LPA observed the sample food from the 4/16/24 lunch menu, which was all fresh food items. Interview with Culinary Director indicated that residents eat a lot of fresh fruit and vegetables in their meals. Interviews with R2 and R3 indicated that the facility provides nutritious meals to residents at the care home. Based on observation, interviews conducted, and documentation obtained, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegations are UNSUBSTANTIATED. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided. The onset date was noted as 7/25/23 and resolved as of 8/11/23. On 12/18/23, the final date that R1 was seen by home health, R1 had a stage two pressure wound on their left buttock and a stage two pressure injury on their right ischial tuberosity. Both wounds were noted to be improving. Interview with Home Health Staff indicated that R1 was receiving wound care approximately once per week. Interview also indicated that how often R1 was seen by Home Health was to the discretion of the Nurse and is based on the pressure injury status. Interview with Home Health Nurse indicated that R1 was receiving care twice per week and was receiving wound care for a pressure injury. Home Health Nurse indicated that they had no concerns regarding the care that R1 was receiving from the care home. Home Health Nurse indicated that they were not concerned with R1’s pressure wound as it was progressing and improving. Allegation: Resident sustained multiple falls resulting in fractures. Interview with R1’s responsible party indicated that R1 sustained a toe fracture in September of 2021. Responsible party indicated that there were other instances that R1 sustained fractures, however, was unable to provide dates of injury. According to Unusual Incident/Injury Report dated 9/13/21, R1 had pushed their pendant and was found by staff sitting on the floor of their bedroom. R1 had reported that their slipper had gotten caught under their mat and they fell. R1 returned from the hospital with a walking boot. The Department conducted a complaint investigation #25-AS-20210916083105 regarding the 9/13/21 fall incident with Unsubstantiated findings. The facility provided all Unusual Incident/Injury Reports for R1 and there was no record of any other fractures sustained. Interview with ED indicated that they are not aware of any falls that resulted in fracture besides the incident that occurred on 9/13/21. No fractures were noted in the Home Health Records between 3/8/23-12/30/23. Allegation: Staff left resident on floor for an extended period of time. According to the facility’s incident log, R1 sustained a fall on 11/28/23 with no injuries reported. Interview with R1’s responsible party indicated that R1 had a fall in November 2023 and R1 did not sustain any serious injuries or fractures as a result of the fall. Facility’s call button log indicated that R1 pushed their emergency call button pendant at 5:01pm. Facility’s incident report indicated that the time of the incident was 5:15pm. **********************************************Continued on LIC9099-C************************************************ Interview with Rocklin Fire Department indicated that the 911 call was made from the facility at 5:15pm. Rocklin Fire Department report #202311280268 indicated that the alarm for service was made at 5:17pm. The report also indicated that Rocklin Fire Department arrived at the facility at 5:24pm to provide lift assistance for R1. The report indicated that R1 had no injuries and was only in need of lift assistance. Interviews with staff (S2) indicated that they were present during the 11/28/23 incident and that 911 was contacted immediately. Interviews with staff (S1) and S2 indicated that the first priority is assessing the resident when they push their emergency call button pendant to ensure the health and safety of the resident. Interviews indicated that, following their assessment, staff would clear the pendant. Interviews with residents (R2 and R3) indicated that staff respond to their emergency call buttons immediately. According to the facility’s Procedures for Resident in the case of an accident or emergency, if a resident has fallen, do not immediately move him/her. Also, if a resident appears to have no serious injuries and the resident is too heavy for two care associates to lift together call 911. Interviews with ED, S1, and S2 indicated that on 11/28/23, staff were unable to lift R1 and required assistance from emergency services. Allegation: Staff did not provide a 60-day notice of rate increases. Interview with ED indicated that R1 had a rent increase while residing at the care home. The facility issued a 60-day notice for rent increase to R1 on 11/1/22. The 60-day notice indicated that rent would increase by $343 effective 1/1/23 and that the enclosed Residency Agreement Addendum Form must be returned to the community Business Office by 12/15/22. The Residency Agreement Addendum regarding rent increase was signed by R1 on 12/15/22. According to R1’s Emergency Information Sheet, R1 is their own responsible party and have a medical Power of Attorney. Facility invoices dated 12/1/22-4/30/23 indicated that the rent increase for R1 became effective 1/1/23. Based on interviews conducted and documentation reviewed, the above allegations are found to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided.