complaint·February 21, 2025

9099C-1.. Allegation: Staff do not provide a sufficient quality of food to resident. The allegation states (R1) is diabetic, and the facility is not feeding her well. On 11/21/24, (R1) was served a hot dog bun with peanut butter for dinner and on 11/22/24, (R1) was given 2 pieces of bread with cheese sauce for dinner. On 11/26/24, (R1) confirmed that she was served a hot dog bun with peanut butter and then top ramen because she is "always hungry" because they do not give her "enough" food. (R1) stated they sometimes offer her mixed canned veggies, applies, bananas, and raw carrot and broccoli, but a fruit and vegetable are not offered at every meal. The Administrator asserted (R1) "always tells us what she want to eat" and not follow the menu, explaining that for lunch today, staff prepared a grilled cheese sandwich and an apple but (R1) has been requesting "hamburgers, mashed potatoes with gravy, and BBQ chicken". The Administrator added that for Thanksgiving, she has placed an order with a local grocery store for their Thanksgiving meal. A family member stated on 12/20/24 that (R1) called 9-1-1 last week because her blood sugar was low and the facility is not serving good food and that another family member of (R1) brings food to the facility. This family member stated the food served is not good and staff are serving a hot dog bun with nacho sauce inside. (R1) stated staff will take an hour to get her cottage cheese and yogurt that her daughter brought to the care home for her. LPA was provided with photos of (4) meal plates served to (R1) during her stay at the facility. One plate showed a bologna sandwich only; a second plate showed pasta noodles with sauce only; a third plate showed a peanut butter sandwich and two cut orange pieces; a fourth photo showed cold cereal and milk with a few banana pieces. On 1/22/25, LPA observed resident (R2) to be eating a chicken bake with fruit and a drink; (R3) was eating pureed food since returning from the hospital recently, and (R4) was eating a chicken bake. On that day, LPA observed more frozen food than fresh food and frozen food consisted of packages of hot dogs, corn dogs and meatballs. There were about a dozen eggs, some grapes, other produce items in the refrigerator. LPA observed an extra refrigerator in the pantry area to contain hot dog/hamburger buns, milk and lots of pantry items, including pasta, Pop-Tarts, canned food, Cream of Wheat, and Oatmeal. *cont on 9099C-2.. 9099C-2.. Under "Basic Services, the Admission Agreement notes that (R1) will receive: 1- Three nutritious meals daily and snacks and 2- Special diets if prescribed by a doctor. (R1's) physician's report also notes that (R1) requires a special, diabetic diet, low in salt that is "easy to chew". Per Mayo Clinic, a diabetic diet should consist of: Balance carbs with fiber and protein in each meal. This is easy if you use the plate method. Make half of your plate vegetables, a quarter of your plate a carb like brown rice, black beans, or whole-wheat pasta, and the other quarter of your plate a healthy protein like chicken breast, fish, lean meat, or tofu. Administrator stated (R1) refused vegetables as they were "too crunchy" and refused all soups and all breakfast except for Cream of Wheat or Oatmeal. The Administrator stated she called 9-1-1 the time it was low, and emergency staff determined that (R1's) arm sensor to measure blood sugar needed to be replaced. The emergency staff tested (R1's) blood sugar using their own test and it was low but not as low as the sensor indicated. (R1) did not have to be sent out. A family member of (R1) stated there were no snacks served so she brought snacks, such as soup, and (S1) refused to serve them to (R1). A second family member stated that after (R1) had low blood sugar, the family brought over candy covered peanuts, and staff placed them on the other side of (R1's) room so she couldn't reach them. The Administrator stated (R1's) blood sugar was never high and was normal on all days but that one day when the sensor needed replacing. (R1) would regularly talk to her doctor. Based on information obtained during the investigation, the Department find the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Allegation: Staff do not ensure that resident's incontinence needs are being met. The allegation states (R1) asked for their adult diaper to be changed, and the caregiver will only change (R1) (3) times per day and (R1) is sitting in their urine all day. The Administrator stated on 11/26/24 she told (R1’s) daughter that the facility "doesn't buy briefs" and the family has not brought any briefs over at all since resident moved in on 11/8/24. The Administrator stated staff will change (R1) when the call light is pressed and that (R1) "will push the button frequently, about every hour". The Administrator asserted that (R1) "told staff they have to manage the diapers and can't change her too often", and “the first two weeks when the facility was buying the diapers, (R1) would call every 45 minutes to be changed". *cont on 9099C-3.. 9099C-3.. On 11/26/24, (R1) stated to LPA that she is changed "usually two times per day" and staff "cannot reposition" her, as staff (S1), stated her back hurts and the Administrator or another staff (S3) are needed to assist. On 11/26/24 (3:20 pm) (R1) stated to LPA that staff have changed her diaper twice today, once after breakfast and then again after lunch, and she needs to be changed again now, and "staff will go 4-5 hours sometimes to check me and they only change me at mealtimes". (R1) stated she is "not sure" if NOC staff are awake or on-call and was also "not sure" if the call buttons are working, asserting she pushed her button three times recently and staff, (S1) took 30 minutes to respond, explaining she "was busy with other clients". LPA observed an unopened package of diapers in (R1's) room on 11/26/24. A family member of (R1) stated she was told at move in that the family provides incontinent products and she ensured that there were always diapers available to (R1). She stated she would bring over (2) large packages, every two weeks, and (R1) never ran out. The family member stated that she also later brought over wipes after learned wipes were not being used and (S1), who provided all the care, was still not using them. The Administrator stated that the facility provides wipes and all staff use them. The family member stated that at least (1) night (R1) was sitting in a soiled diaper. Based on information obtained during the investigation, the Department find the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Allegation: Staff do not ensure that resident's showering needs are being met. The allegation states (R1) has not been bathed for about a week and when (R1) asked for a bath, the caregiver refused to give them one. On 11/26/24, the Administrator explained that she "has been calling home health every other day" to arrange for Physical Therapy to come out but has not heard from Home Health since (R1) moved in, on 11/8/24. The Administrator stated that "two to three times per day, (R1) goes BM all over her bed and we have to clean the sheets", and "every other day, (R1) receives a bed bath". The Administrator agreed to go to speak to the home health social worker the next day, and advised LPA that she had been informed home health was discontinued due to resident’s insurance coverage. *cont on 9099C-4.. 9099C-4... On 11/26/24, (R1) stated she received her "first bath yesterday", which was "brief". A family member stated that (R1) received (2) bed baths during the time she resided at the facility and (S1) gave her the first one and the Administrator gave her the second one, on/around 12/31/24. This family member stated that (S1) "grabbed a cold wash cloth and gave (R1) a quick wipe down". The family member stated that (S1) would not strap (R1's) correctly which may have caused (R1's) bedding to become soiled and need changing frequently. The family member stated that the facility "had all the equipment " to provide the ADL's but didn't and the family was not aware the care was not being done, until about (2) weeks after (R1) moved in and the family was informed they couldn't move (R1). The Administrator informed LPA that (S1) was let go as a employee on/around January 2025. Based on information obtained during the investigation, the Department find the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations,Title 22, Division 6, Chapter 8, the following (3) deficiencies are being cited on the 9099-D pages. Exit interview. Copy of report and appeal rights provided. 9099A-C-1.. (R2) responded that staff " let me turn them on during the day but I like to sleep with the light off at night". The Administrator stated a resident can leave the lights and television in their room all day and all night and (R1) would keep the television on all night. LPA observed night-lights in the common areas Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- a finding that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violations occurred. Allegation: Staff do not ensure that resident is receiving their medication as prescribed. Allegation states (R1) is prescribed an antidepressant medication, Wellbutrin, and staff haven’t administered the medication since (R1) moved in. On 11/26/24, the Administrator stated (R1) moved in with 14 days of medications, but there were "4-5 missing medications", based on the medication list (R1) moved in with, and she let (R1’s) daughter know, a week ago. The Administrator stated she "doesn't know” the medication, Wellbutrin, and the "daughter is handling all the medications". On 11/26/24, (R1) stated she ran out of the antidepressant, Wellbutrin, commenting she thinks the prescription had run out and explained the request for a refill was "just sent in" but she is not sure if it was approved. LPA observed that (11) medications were logged as started on 11/8/24, including at least one medication for diabetes. (R1's) family member stated that (R1) may have not had this medication at the beginning but eventually got the medication filled, confirming she would pick up and deliver all medications to the facility for (R1). Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- a finding that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violations occurred. Exit interview. Copy of report provided to Administrator.