Inspector’s narrative
What the inspector wrote
The external incident report does not note any contacts made with family members. Under a section titled “Agencies/individuals notified,” the author of the report only indicated that CCLD was notified. Under a section titled “Explain what immediate action was taken (include persons contacted),” the incident report states that the resident was evaluated by a staff member and emergency responders were called. The report does not state any further contacts were made. LPA Moleski interviewed a former executive director (ED1), who indicated that, to his knowledge, no report was made to R1’s family members. R1’s power of attorney (POA) said she was not notified by the facility of the incident. LPA Moleski reviewed a random sampling of four incident reports from August and September 2022 from this facility, including another incident report involving R1, and found that four of these reports identified a responsible party who was contacted. During interviews, a former executive director (ED2) and two former staff members (S3, S8) were unsure if notification was made to R1’s POA.
In interviews, ED1 said R1 was given food items contrary to R1’s prescribed diet, such as high-sugar foods. Another former executive director, (ED2) said the same. Two of two dining staff members interviewed (S5, S6) also said R1 was given food items contrary to R1’s prescribed diet, such as dairy products and high-sugar foods. Meal tickets for R1 reviewed by LPA Moleski often included requests for creamer. During an interview, R1 said she was served dairy products. R1’s LIC 602 dated 12/16/22 states that R1 is allergic to milk and milk products, among other things. R1’s functional needs assessment, dated 12/22/22, indicates that R1 needed a diabetic diet.
The department has determined the following as it relates to the allegations that the facility is not following resident’s prescribed diet and that the facility did not notify POA of hospitalization:
Based on interviews and review of facility records, the above allegations are SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met.
This facility is being cited per 22 CCR Sections 87211(a)(1)(B) and 87555(b)(7). An exit interview was held with Leach. Appeal rights and a copy of this report were left with Leach.
LPA Moleski reviewed an external incident report that was faxed to the Community Care Licensing Division on 9/16/22. According to this report, R1 was walking to the couch in the living room of R1’s apartment and fell. According to this report, R1 was not wearing a call button pendant at the time of the fall. LPA Moleski interviewed a staff member (S3) who responded after R1’s fall. S3 said there weren’t any fall risk hazards present in R1’s room at the time.
LPA Moleski interviewed seven residents (R2-R8). R2 said there was adequate staffing but call response times were an issue. R4 expressed concerns regarding staffing and call response times. R7 said there was adequate staffing when staff are available, but when staff call out there are not enough staff to fill in. R7 did not voice concerns regarding call button response times. R3, R5, R6, and R8 did not express concerns regarding the current levels of staffing or call button response times. LPA Moleski interviewed four staff members regarding staffing levels. S3 and S4 did not voice concerns regarding staffing or call button response times. S5 and S6 did not voice concerns regarding staffing. LPA Moleski reviewed call button response times recorded for the rooms R1 lived in. The average response times for R1’s rooms were all below five minutes.
LPA Moleski interviewed two former executive directors (ED1, ED2) regarding contacts made with an ombudsperson. Both ED1 and ED2 said they were not aware of any request to forward information to an ombudsperson. LPA Moleski interviewed an ombudsperson, who was not aware of any such request. LPA Moleski reviewed an email between ED2 and R1’s power of attorney (POA) dated 9/1/22, in which ED2 provided a phone number in response to a request for contact information for the ombudsman’s office.
LPA Moleski reviewed a letter addressed to R1 and R1’s POA, dated 8/31/22. The letter describes an increase in rent prices and provides an explanation for the increase. According to the letter, the increase was to go into effect as of November 1, 2022. An address was listed at the top of this letter. During an interview, R1’s POA said this was a mailing address for R1 and R1’s POA. R1’s POA said they never received the letter.
[continued on 9099-C]
While inspecting R1’s room on 5/12/23, LPA Moleski observed posters affixed to the interior of R1’s apartment door. The posters contained information regarding fire drills. The posters direct the reader on what to do in the case a fire alarm goes off. If a fire alarm is set off, residents are to stay in their room if safe and await further instructions from staff, according to this poster. LPA Moleski interviewed a former executive director (ED1) regarding further instructions in the event that staff do not provide further instructions. ED1 said residents were given further information at three town hall meetings. LPA Moleski reviewed town hall meeting notes for meetings held on 1/26/23, 2/23/23, and 3/23/23. The notes indicate that fire drill instructions were discussed during each of these meetings. ED1 said that, during the January and February meetings, residents were instructed to consider the situation all-clear if there are no further instructions.
The department has determined the following as it relates to the allegations that the facility is not adequately staffed, that the facility does not respond to call pendants timely, that the facility did not ensure resident safety resulting in serious injuries, false statement, that the facility did not provide explanation of increase in rent to POA, and that the facility did not ensure resident received instructions during fire drill:
Based on interviews, observation, and record review, the above allegations are UNSUBSTANTIATED, which means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.
An exit interview was held and a copy of this report was left with Leach.
During an interview, S7 said the breaker flipped in this room once or twice due to the devices that were plugged in. S7 said staff were directed to utilize another outlet and had no issues afterward. LPA Moleski reviewed an incident report from this facility that described an incident on 8/8/22 wherein a water heater leaked into R1’s bedroom. The incident report describes steps taken by this facility to address the leak. LPA Moleski inspected the room where the leak occurred and observed no physical plant deficiencies.
LPA Moleski reviewed staff transfer training records dated January 25, 2023 and an all-staff training sign-in sheet dated April 26, 2023.
LPA Moleski reviewed an incident report regarding a fall suffered by R1 on 9/13/22. The incident report was received by the Community Care Licensing Division (CCLD) via fax as of 9/16/22.
The department has determined the following as it relates to the allegations that the facility is not addressing physical plant problems, that the facility is not providing training for resident transfers, and that the facility is not reporting incidents to CCLD:
Based on observation, review of facility records, review of licensing records, and staff interview, the above allegations are UNFOUNDED. A finding that the complaint allegations are unfounded means the allegations are false, could not have happened or are without a reasonable basis.
An exit interview was held and a copy of this report was left with Leach.
