Inspector’s narrative
What the inspector wrote
Continued from LIC 9099
According to Staff 1 (S1), Staff was unaware that R1 left during the entire morning shift. According to an interview with Resident 1 (R1), R1 was unable to recall the incident; however, R1 was able to express how one would call for help if needed.
Due to the incident, R1 was placed on alert charting and to be checked on every hour. Staff are required to sign a hourly check sheet to state the staff saw R1 inside the facility. Based on records review, NOC shift hours 10:00 PM - 6:00 AM are rarely completed. 7 out of 28 days reviewed were signed off by staff. AM Shift, 6:00 AM - 2:00 PM, filled out the hourly log 21 out of 28 days. PM shift, 2:00PM - 10:00 PM, filled out the hourly log 19 out of 28 days. Although an hourly check log has been implemented, staff do not ensure they are completing the hourly checks.
Based on records review, and interviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, citations for deficiencies can be found on the LIC 9099 -D. Failure to correct deficiencies may result in additional civil penalties. Appeal Rights provided. An exit interview was held, and a copy of the report was provided.
...Continues from LIC 9099 - A
LPA reviewed July 2023 Medication Administration Records (MAR) for R2. The MAR orders match the Physician Orders provided. LPA observed MAR notes indicating when the resident was out of the facility. On the days the resident was in the facility, staff signed off for each order in the MAR. LPA attempted to interview R1; however, interview was deemed unsuccessful. Records show the facility obtained a new LIC 602 dated 07/23/23.
Based on all the information collected by the Department there is not a preponderance of evidence to prove the allegation occurred, therefore this allegation is UNSUBSTANTIATED. Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore the allegations are unsubstantiated.
Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview was held and a copy of report was given to Program Director Caleb Summerhays.
...Continued from LIC 9099 - A
LPA interviewed Staff 3 (S3). S3 stated that the facility has improved over the years in regards to quality of food. S3 feels that the residents are fed well and they are given balanced meals. Residents are involved in the menu planning process. S3 stated that if the facility needs to change the menu, they are able to update it weekly. S3 stated that snacks are offered in the morning, in the afternoon, and in the evening time. Residents are able to request additional snack items while the kitchen is operating. Before kitchen staff leave for the evening, the kitchen staff will prepare sandwiches and/or leave fruit and other food options out in the dinning hall. According to an interview with a resident's family member, the family member feels the residents are fed well. The family member stated the resident has not complained of the food and the resident has lived there for many years. According to an interview with Resident 3 (R3), R3 loves the food, is able to get snacks, and has a personal fridge for after hour items.
Staff does not ensure that residents are properly assessed for medical issues
According to an interview with S2, S2 is in charge of assessing all new intakes. S2 stated there has never been any residents that have not been assessed. S2 informed LPA that if any resident needs to be sent out, they will be sent out. S2 stated the facility is constantly calling doctors to update the resident's LIC 602. According to records reviewed by LPA, records were observed to have a pre-appraisal, an updated needs and services plan, and an updated LIC 602.
Staff does not ensure that residents have dental hygiene products.
Staff does not ensure that residents have bedding.
LPA observed the facility. LPA observed the cleaning supply closet, two (2) linen closets, and two (2) supply closets. LPA took pictures for reference. The cleaning supply closet was stocked with toilet paper, paper towels, cleaning supplies for the bedrooms and bathrooms. The linen closet had 3 shelves full of towels, bedding, and comfortersThe second closet also had a linen closet full of bed sheets and comforters. According to S3, S3 stated anytime a resident ask for items, the staff put the code in to get the items. It is usually fully stocked. They have a main one they use, and they have a back up supply.
Continues on LIC 9099 - C...
...Continued from Page 2 of LIC 9099 -C
LPA interviewed residents. R4 stated bedsheets are brought by family. Any items R4 needs, the family sends it in a package. R5 stated the facility helps with the bedsheets every Tuesday. R5 was observed to have dental and hygiene products in the bathroom. R6 stated R6 does not remember when staff change the bedding, but knows that "they just do it.". R6 was observed to have hygiene supplies and dental supplies located in R6 bathroom.
Staff does not ensure that facility is at a comfortable temperature for the residents.
The facility was observed on 08/01/23, 08/23/23, 09/12/23, and 09/28/23. During each visit, the facility temperature was observed to be within the regulatory range, which is
a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat to 30 degrees F less than the outside temperature.
Based on observations, interviews, and record review, the aforementioned allegations are unfounded and the allegations are false. Per California Code of Regulations, Title 22, Division 6, chapter 8, no deficiencies are being cited. An exit interview was held, and a copy of the report provided.
