complaint·December 27, 2023

Resident Care Manager, Patrica Russell addressed the additional witness’ concerns and in conjunction with additional witness, revised R1’s care plan. The care plan ensured that R1 would be checked on every hour and changed if needed. LPA reviewed records from the facility, in which additional witness requested facility staff implement every shift. LPA also reviewed documentation from the revised care plan and requested information regarding the communication between the facility and the hospice nurse. The information stated that there was a request in changing chucks due to excessive weeping from the wounds. LPA interviewed residents who stated that there were no issues with asking for assistance with an assistance in daily livings, which include incontinence matters. LPA interview staff, who indicated that they followed the new directive plan given to do rounds every two hours and after the revision of the care plan, increased checks on R1 every hour. Resident Care Director, Patrica Russell stated that the facility has been implementing the new procedures after the concerns were addressed to Resident Care Director. Based on LPAs observations and interviews which were conducted and record review(s), in regards to the allegation of staff do not ensure a safe and healthful environment by not assisting a resident with incontinence needs, the preponderance of evidence standard has been met. Therefore, the above allegation(s) is found to be SUBSTANTIATED. This poses a health and safety and or personal rights risks to residents in care. California Code of Regulations, (Title 22, Division 6 Chapter 8 Article 11. Health-Related Services and Conditions, 87625 (b)(3) ), are being cited on the attached LIC 9099D. An exit interview was conducted. A copy of this report, LIC 9099-D, and appeal rights were discussed with and provided to the Executive Director, Tammy Eddy.