complaint·January 21, 2022

Regarding the allegation of, resident sustained fractures while in care, the Department found the following: this allegation was investigated by the Department of Social Services Investigative Branch (IB). Based on medical record review and interviews, IB determined that Resident 1 (R1) may have sustained fractures, but CT scans/images couldn’t determine if they were fractures or not. R1’s doctor was interviewed and stated that R1 had three possible acute fractures along her spine, which means based on CT imaging, R1’s doctor could not be certain if what she saw were fractures. And if they were fractures R1’s doctor could not determine the age of these fractures, whether they were new or old. IB has deemed the complaint findings as UNSUBSTANTIATED. Regarding the allegation of, Facility did not accept resident back after a hospital visit, the Department found the following: based on interviews it was determined that, Kaiser called the facility and spoke with a newly hired LVN Staff 2 (S2), who didn't understand the verbiage so he provided wrong information to Kaiser. Once the Administrator found this out, the Administrator immediately called R1's responsible party to explain the confusion and stated that R1 was able to come back to the facility and S2 called Kaiser back to explain the confusion. By this time R1's responsible party already found another care facility. Regarding the allegation of Facility did not notify resident's representative in a timely manner of a change in resident's needs for a higher level of care, the Department found the following: based on interviews and record review it was determined that, the change in R1's needs happened when R1 was sent to the hospital for the latest fall. R1's responsible party was notified of this fall. While in care R1 remained at level 1. Regarding the allegation of Resident's room was not properly cleaned while in care, the Department found the following: based on observation and interview it was determined that, Administrator stated that staff left R1's room exactly the way it was after R1 moved out. 2 different LPA's observed R1's room to be clean. Regarding the allegation of Resident was unkempt while in care, the Department found the following: based on interview with the Department's Investigative Branch, the Investigator stated that he/she only saw video of R1 at night time. R1 didn't appear to be neglected, dirty, or not cared for. R1 was in his/her pajamas with his/her hair messy, but appropriate for bed time. The investigator did not see any video of R1 during the day. Report continued on LIC9099-C... Regarding the allegation of Resident sustained a pressure injury while in care, the Department found the following: based on interview and record review it was determined that, R1 did have redness on the coccyx and a small open area (1cm x 1cm) on the buttocks, which was resolved by the physician and Kaiser home health. Care staff noticed this before it got bad. Per the Administrator, R1 was given the option for phyiscal therapy and activities but R1 refused and wanted to stay in his/her recliner. Regarding the allegation of Facility did not have sufficient staff to meet the residents' needs, the Department found the following: based on record review and interview it was determined that, the facility had at least 3 caregivers on shift during the night, which falls in line with Title 22 regulations. Regarding the allegation of facility did not request for an exception to use recliner instead of bed, the Department found the following: based on interview and record review it was determined that, R1 was not to put to bed in the recliner, it was R1's choice to stay in recliner. Per Administrator night shift would make their rounds and R1 always wanted to stay up a little longer and watch tv. R1 would normally get out of the recliner and go to bed. Per R1's care plan, R1 was able to transfer independently. Regarding the allegation of Facility staff are not adequately trained, the Department found the following: based on record review it was determined that, care staff have all updated training. S1 admitted to making the mistake of not visually seeing R1, and S1 knows he/she was wrong and owned up to it. S1 does have up to date training. Although the allegations may have happened and/or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted with Administrator Mike Talani. A copy of this report was left with Administrator upon exit. R1 lays on the ground until the next morning. It was noted that a caregiver came in R1’s room some time between 5am and 6am to drop off laundry but didn’t actually go all the way in R1’s room so the caregiver never saw R1 on the ground. At 8:02am a med tech came in R1’s room and saw R1 was laying on the ground, this is when staff called the paramedics. IB noted that care staff stated that the frequency of resident checks varies throughout the night, however staff try to check on residents every 2 hours unless their care plan states otherwise. Based on interviews and video footage review, the preponderance of evidence standards has been met, therefore, the above allegation(s) is/are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099D during this visit.