complaint·October 10, 2024

9099C-1.. Allegation: Staff do not ensure that a resident's incontinence needs are met. Allegation states that for more than one year, staff have not ensured that resident’s (R1) Depends Diapers are changed regularly as resident has been observed to be wearing soiled diapers and soiled pants on several occasions when she is visited. LPA reviewed multiple e-mails exchangeed between resident's family member and the Administrator where the family expressed concerns that (R1) wasn’t regularly checked and provided with incontinent care. On 12/30/23 , the family member described when she was visiting and found resident to be “wearing a shirt as underwear, no Depends and a used piece of toilet paper in her sock”, which made the family member think maybe (R1) hadn't been checked on in a while, had an accident, and tried to change herself. A photo was provided to the Department matching this description. A follow-up email was sent to the Administrator 2/3/24 and included a photo of resident wearing an incontinent pad, taped around her, instead of a “diaper”, and the pad "was undone and very bulky under her pants", which were reported to be too large as they belonged to another resident. The Administrator stated that staff will use the “tape kind” of diaper because (R1) won’t let staff take their pants or shoes off. Resident's family member sent another email, on 3/30/24, to report she immediately noticed a soiled diaper on resident when visiting earlier that evening, and the resident’s pants were soiled also. The family member stated that, during another recent visit, resident was wearing a soiled diaper that also needed immediate changing and inquired what procedures are in place to ensure residents don’t go extended periods with soiled Depends. The Administrator responded that staff are to be “making their rounds every 2 hours”. On 5/11/24, the family member emailed the Administrator, asking her to call her to discuss multiple concerns, and provided the Department with a summary of the concerns, which included, finding (R1) in "wet Depends" when she visited earlier that day. On 6/3/24, the family member emailed the Administrator requesting staff check resident (R1) “more often than she currently is” being checked, stating, “More often than not when we visit her, she's in a soiled Depends and we have to request help for it”, referencing the prior day's visit when resident needed changing right away when they arrived. The family member stated that based on her conversation with resident’s day program, the facility is sending (R1) to their program in the morning in soaked depends and provided a photo of resident’s sweat pants being wet from a soaked diaper, only after being at the program for (2) hours. The Administrator responded, by email the same day , that the day program will often return residents to the community in soaked depends. *cont on 9099C-2 9099C-2.. (R1's) charting notes, on 6/3/24, state the Administrator and Resident Care Coordinator will begin documenting each resident has been provided with incontinent checks before leaving to, and after returning from program. On 6/6/24, the Administrator noted that resident returned from day program with a “soaking wet” diaper. Resident's Pre-Appraisal completed on 12/30/22 indicates that (R1) needs assistance with toileting, including after using the toilet and changing her Depends. The care plan that was completed on 6/15/24 and notes resident needs maximum assistance with toileting, “resident to be checked more frequently for incontinence” and to check after returning from her health care day program. Additionally, the care plan states the Administrator is making Incontinence care a "special care need" due to resident not cooperating much with changing- may take 2-3 caregivers to help with resident to provide distraction to get done and to provide checks when resident is in her room and common area. The care plan indicates that safety checks are to be done (4) times in a shift. (R1's) family member provided additional instances when resident was found in a soiled diaper when she was visiting. Specifically, on Friday, 6/28/24, and on the weekend of 7/27/24 and 7/28/24, around 3:00- 3:30 pm, each day. LPA also reviewed a text message sent by the family member to the Administrator, on 8/27/24, to report that (R1) was found in soiled Depends. The text says the family member had one staff call on the walkie for assistance, but there was no response for (10) minutes, so the family member changed the resident herself. Also on 8/27/24, a second resident (R2) was observed to be wearing “pants that were completed soaked” and a “puddle beneath her” in the dining room, and a photo was provided to the Department. The Administrator stated on 6/13/24 that "(R1) is very difficult and it sometimes takes lot of tries" to change her. One "am" care staff stated on 7/3/24, that resident's family member visits usually on Saturday, during the "pm" shift and it "may be an issue" then with (R1) not being changed timely. This staff commented "one time (R1) was wet" at the start of her shift and "sometimes she is soaked and two times, (R1) went bowel movement on me". Another staff stated (R1's) Depends can become very wet "sometimes when she is sleeping", and when (R1) is awake, she "always takes her to the bathroom", but "sometimes she (R1) doesn't want to move, so I will change her Depend on her bed, commenting "(R1) cooperates with encouragement and reminders". *cont on 9099C-3... *9099C-3.. (R1's) family member stated she usually visits in the evenings, after dinner, around 7:00 pm, and also on the weekends, around 3:00 pm, and when she checks (R1) her "Depends are soiled". The family member indicated that the facility is "maybe understaffed" during the times she visits and that she never visits before noon, asserting that 50% of the time she checks, (R1) is soiled and her pants (clothing) are also wet. Based on information obtained, LPA finds 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 a resident's personal care needs are met. Allegation states 1)since September 2023, staff have not applied resident (R1's) eczema lotion to her body, and 2)Dentures are also not cleaned daily. 1) Resident's family member stated (R1) has had issues with eczema since September 2023 and facility staff have applied the prescription creme "off and on" only, stating she is "not sure how often they are putting the lotion on". Resident's (R1's) Charting Notes entered on 10/31/23 document that caregivers showered resident and noticed a rash all over her body and called a Med-Tech staff and the Resident Care Coordinator. The notes state that the rash covers all of (R1's) left side and on right side thigh, and that her medical group was contacted to send cream, and the facility is waiting on an order. Notes say the family was contacted. The Department reviewed an email sent form (R1's) family member to the Administrator, on 2/3/24, to inform of a rash on (R1’s) left thigh that the family member has observed for the last several visits and asks that the rash be attended to. The Administrator responded the same day that she will reach out to resident's health care group for advice. A follow-up e-mail was sent to the Administrator, on 2/28/24, to advise that (R1) was scratching the rash on her thigh and it looks “bad again” and to request it be attended to. The Administrator responded promptly that she will ask a Med-Tech to follow up with (R1's) health care provider regarding a possible change in the order for the cream/ointment being used. Another follow-up e-mail was sent to the Administrator, on 3/7/24, advising (R1's) rash is “worse”- as it has spread to the backside of her thigh and on her right arm too. *cont on 9099C-4... 9099C-4.. Another follow-up e-mail, with photos, was sent on 3/24/24, to the Administrator to advise that (R1) needs medicated lotion for her rash due to break outs on her right arm, right thigh and now on her chest, explaining that (R1) was scratching her thigh and chest while visiting this evening. The Administrator responded she would reach out to get medication lotion and to schedule an appointment. Another e-mail was sent, with photos, on 3/30/24, to advise the Administrator that the resident’s skin is “not getting better”, has spread more, and resident was scratching herself again when the family member visited tonight. The family member asks if resident's health care provider should be involved. Resident's charting notes made on 4/1/24 document the Administrator had reached out to the health care provider due to skin issues. MAR documentation shows (R1) had an order for Eucerin Eczema Creme (1%) effective 9/20/23 through 5/9/24. Resident charting and MAR combined show that resident refused Eucerin cream on 4/22, 4/24, 4/27, 4/28 and 4/30 but on 4/29/24 (11:00 am), the Med-Tech was able to apply Triamcinolone crème and partially apply Eucerin since she had just applied the other treatment. Notes from 4/29/24 (8:22 pm) document cream was applied from chest to legs, and on 4/30/24 (9:17 pm) notes state "Resident did well today- no refusals and cream was applied. Also on 5/1/24, the resident allowed Med-Tech to put cream on. Administrator documented in Charting notes on 5/10/24 and 5/11/24 that she observed resident to have received a shower with tea tree oil body wash and lotion due to eczema. Family member sent photo taken on 6/8/24 showing eczema breakout had spread to (R1's) stomach/thighs. Doctors later determined the rash on resident's stomach only may have been a reaction to Bactrim. Resident's family member provided a photo taken on 7/1/24, after resident was admitted to the hospital and commented in an e-mail how "dry (R1's) skin was when she got to the Emergency Room". LPA was provided with a subsequent photo taken only one day later, on 7/2/24, where (R1's) ankle looked much better and not nearly as red and irritated. Resident's family member stated she put lotion on her while visiting (R1) in the hospital. On 7/3/24, the RCC stated (R1) has been using (2) different creams for months, and currently (R1) is taking Eucerin and Triamcinolone (.5%), a 14- day prescription, and "only Med-Techs will apply the prescription cream, on shower days (am), and caregivers can apply non-prescription cream/lotion. June MAR shows Triamcinolone cream was administered twice daily from 5/28/24- 6/4/24 only; the order was to apply the cream up to (14) days- there are no notes as to why the cream was stopped on 6/4/24.. *cont on 9099C-5.. 9099C-5.. .MAR documentation shows another creme, Triadime, was ordered to start on 6/27/24, and this cream was only administered in the morning, on 6/27/24, by the Administrator. There are no additional days initialed in June documenting that the cream was administered. On 7/3/24, a caregiver stated that both caregivers and Med-Techs put cream on (R1's) legs, arms, stomach and back and "sometimes (R1) refuses", as she has observed her do with other caregivers. Resident had returned back to the community from the hospital on 7/4/24. The family member stated that on 7/6/24- (6:57 pm), she was "visiting with (R1) and her arms are already broken out again" commenting, "it looks awful again". Two photos were provided showing how resident's lower arms were broken out. Resident's family member stated another family member was visiting with (R1) on the evening of Wednesday, 7/10/24, and observed (R1's) arms, chest, and neck to be red, and she was scratching. The family member applied CeraVe healing ointment on her arms. A photo was provided on 7/11/24 showing resident's lower left arm to be red and broken out. Resident's family member stated she found (R1's) skin "dry and irritated" on both days on the weekend of 7/27/24 and 7/28/24, and she put lotion on herself. Based on information obtained, LPA finds this portion of the allegation to be SUBSTANTIATED - 2)- Resident's charting notes, created on 10/20/23, document that the Ombudsman visited with the Administrator today regarding oral hygiene care not being provided regularly to (R1). The notes further document that on 9/22/23, the Administrator and resident's family member discussed these concerns and that the Administrator has been checking in with staff to make sure this care was being provided. The notes further state that on 10/20/23, the Ombudsman observed them to be clean with the comment added “it’s a hit or miss that resident will let staff take out her dentures to clean them” and to try a change of face if resident refuses. Resident's family member e-mailed the Administrator on 2/14/24 to request an update on oral hygiene care for (R1), stating it doesn’t look like (R1) is receiving regular care as every time she visits, she sees “a lot of plaque and gunk built up on her dentures”. The Administrator promptly replied she would follow up with staff again to ensure (R1’s) teeth are brushed and set up a system where staff let her know when it’s been completed. A photo was provided that was taken on the evening of 2/13/24, showing significant build-up on (R1's) dentures. *cont on 9099C-6... 9099C-6... A care staff who stated she sometimes works on both the "am" and "pm" shift, explained she will place the dentures to be cleaned around 8:00 pm when (R1) goes to sleep and will place them back in (R1's) mouth when she wakes up for breakfast, which is sometimes around 9:00 am. This staff explained that (R1) has a container where her dentures are cleaned/soaked over night. LPA asked if other "pm" staff will clean (R1's) dentures. This staff stated "yes, "pm" staff will always ask for help as sometimes (R1) wants another staff to clean her dentures", and commented "(R1) is always comfortable with me, but sometimes other "pm" staff will ask me to help since (R1) is comfortable with me" adding she has "never seen (R1's) dentures dirty". Another staff stated " every morning, before breakfast, I rinse her dentures and after lunch too". Resident's family member stated when she visited (R1) on 5/11/24, she observed "lots of gunk on dentures" and she spoke to the Administrator about the her concerns following the visit. Photo documentation was provided showing (R1) had a lot of gunk built up on her dentures on 6-19-23, 9-21-23, 2-13-24, and on 5-11-24. LPA was not able to observe resident's dentures on 6/13/24 (11:00 am) as she was asleep in her room. On 7/3/24, resident was not present at the facility during LPA's inspection, and on 7/11/24, resident was not in her room at the time of LPA's inspection in the morning, and LPA was only able to observe resident leaving around noon for an appointment with her health care provider. Resident's Pre-Appraisal notes resident "depends fully on others for personal hygiene". Resident's care plan, dated 6/15/24, indicates resident is "full assistance with oral care" in the morning and bedtime, and also "needs assistance with setting up oral care for dentures, and assistance with cleaning dentures". Text messages were reviewed from 6/15/24 (8:36 pm) where the Administrator stated (R1) was refusing to allow staff to take her dentures our or brush her teeth. Based on information obtained, LPA finds this portion of the allegation to also 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 (2) citations are issued on the 9099-D page. Exit interview. Copy of report and appeal rights provided. 9099A-C-1... Resident's family member stated on 6/10/24 that all of (R1's) clothes are clearly labeled, but she has seen other residents wearing her clothes. Resident stated that a bag of (R1's) clothes were also thrown away due to the scabies outbreak a few months ago; however, reimbursement was given to the family for the clothes that were thrown out. Resident's family member stated that she has been told by the Administrator that other residents are taking (R1's) clothes; however, she visits the community three to four times per week and has "never seen any residents entering mom's room to take clothes". One laundry staff indicated on 6/13/24 that "all clothes are labeled with the resident's room # or name", and if there is no room # or name, staff will hang it up and place it on the rack located in the laundry room which is the "lost and found". LPA observed the rack that the staff pointed to during the interview. Staff further stated that "resident laundry is mixed; however, she and other staff will "separate bedding from clothes" and confirmed that mixing resident dirty clothes when doing laundry "has always been done this way". One care staff, who works on the "pm" and "NOC" was interviewed and was working at the community in June, 2024, stated that resident (R1) would often place her glasses on top of her armoire and the glasses would often be found behind resident's bed, as she insisted on wearing them to sleep. This staff stated (R1's) glasses were found in her blankets, and in the couches in the common areas where she would also take naps.The care staff stated that many residents at the community "shop" in other residents' rooms and take clothes from closets that do not belong to them, due to their diagnosis of Dementia. LPA and the caregiver looked through a box containing many pairs of "lost" glasses and did not observe (R1's) glasses. This staff stated staff will place any clothing found in the correct closet in resident's room. LPA observed eye glasses to be clean on 6/13/24, 7/3/24 and on 7/11/24, when inspecting resident's room. LPA also observed detailed information, with pictures included, regarding resident's glasses, to be posted in resident's room for staff to refer to. Instructions asked that staff contact resident's family member if any pair of glasses is lost and cannot be found and provides a contact number. Also observed was a box of lens wipes for staff to use. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview. Copy of report provided.