complaint·February 6, 2025

9099C-1.. Allegation: Licensee does not ensure facility floors are maintained in clean condition. The allegation states that carpets in the facility have not been cleaned and have large stains. On 10/21/24, the LPA and Ombudsman toured the interior of the facility to observe the condition and cleanliness of the carpet. The carpet near the hallway area by room #107 appeared to be heavily stained. In the hallway, near room #135, a large puddle was observed as well as an incontinent urine smell and heavily soiled carpet by the door. The Ombudsman reported that a follow up inspection was conducted on 11/1/24, and the carpet was observed to have been recently cleaned in both of these areas after bringing it to the facility's attention . On 1/29/25, LPA observed a large carpet stain near room #133 and in the hallway near the laundry room by room #110. In other areas of the community, the carpet appeared to look clean; however, the solid carpet piece at the corners of the hallways had some marks, which the Maintenance Supervisor indicated wheelchairs can cause. A family member stated the carpet was visibly very soiled with stains on/around September thru October 2024, and there was an odor present also in the hallway. The family member stated the carpet was much better starting in late October as it had been cleaned recently. Carpet cleaning schedules confirmed the carpet was cleaned on 10/23/24, and again on 11/7/24, by a new company. LPA observed both dining rooms to be clean and free from food or beverage spills on the floors on 10/21/24 and on 1/29/25. The maintenance supervisor stated on 2/6/25 that facility carpets, including in resident rooms, are professionally cleaned every 2.5 months, and he will clean any new spots, as needed, with the facility shampooer. Additionally, housekeeping will vacuum carpets daily. The maintenance supervisor stated that the facility started using another outside professional carpet cleaning company in October 2024, and the next cleaning is scheduled for around the end of February 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 (1) citation is issued on the 9099-D page. Exit interview with the Administrator. Copy of report and appeal rights provided *cont on 9099C-2... 9099A-C-1... Allegation: Licensee does not ensure sufficient staffing to meet residents’ care needs. The allegation states the facility is very short staffed so the staff are unable to properly assist the residents with their care needs. LPA reviewed staffing schedules for all shifts in October 2024. All shifts showed (4) caregivers minimum and (2) Med-Techs during the "am'" and "pm" shifts and (2) care staff and (1) Med-Tech staff during the NOC shift. LPA also reviewed (40) resident shower schedules for the month of October 2024, from 10/1/24 through 10/21/24. LPA observed schedules to be consistently initialed by facility staff as completed or refused by resident. Most schedules showed residents were receiving a shower for an average of two times per week and some schedules noted when hospice staff gave the shower. LPA reviewed charting notes for (R1) from March 2024 through January 2025. LPA observed that it is documented many times that (R1) refused all ADL care, and could be agitated and combative at times, even when (2) staff attempted to assist resident. The Resident Care Coordinator stated staffing levels are sufficient and (R1) would/will regularly refuse care, food and medications. The Administrator stated (R1's) falls have nothing to do with staffing levels. Based on information obtained, the above allegation is found 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. *cont on 9099AC-2... 9099AC-2.. Allegation: Staff neglect resulted in resident sustaining multiple unwitnessed falls. The allegation states (R1) has had multiple unwitnessed falls and staff are not adequately supervising (R1) because of the short staffing. (R1) did not require any medical care after the falls but did have bruising on the face as a result. LPA reviewed charting notes for (R1) and incident reports and noted the following (4) falls: On 3/27/24 (7:30 pm), (R1) was observed on the floor in hallway after an unwitnessed fall. (R1) was sent to the Emergency Room. On, 4/5/24 (12:50 pm), (R1) walked to the front reception area and informed staff she had fallen and was observed to have a knot and bleeding on their head. (R1) was sent to the emergency room following this incident also. On, 9/1/24 (10:10 pm), (R1) sustained an unwitnessed fall and was observed to have scrapes and a bloody nose. (R1) was sent to hospital and returned to the community on 9/2/24 (3:00 am). Notes say Med-Tech confirmed that (R1) did not suffer any other injuries than the facial ones and was given creme. On 9/9/24 (10:30 pm), (R1) was observed following an unwitnessed fall. Notes say resident hit their head. LPA was provided with a p hoto showing (R1) had sustained (2) black eyes, in September 2024. LPA was provided with another photo, taken on/around 10/10/24, showing bruising on both of (R1's) upper cheeks. (R1) was sent to the hospital and returned 10/11/24 (10:31 pm) with no changes in medications. Staff (S1) was interviewed and indicated they are not aware of any falls and/or bruising (R1) has sustained and they are able to successfully provide care and administer medications to (R1), without (R1) being combative. (S1) stated he has observed bruises on other residents and it's usually from "two residents trying to squeeze through a hallway", commenting he have been bruised before. (S1) and the Resident Care Coordinator stated they have never seen (R1) use a walker. Notes for (R1) document multiple times when resident was wandering throughout the building at night and during most of the day. (S1) suggested that (R1) may have fallen as their "knees were tired" from walking a lot during the day and at night, causing them to fall. (S1) confirmed on 2/6/25 that (R1) had a recent medication change to medications, Losartan and Trazadone, and (R1) now sleeps much better through the night. *cont on 9099A-C-3.. 9099A-C-3..(R1's) care plan was updated on 12/5/24 to reflect an increase in care needs in the areas of bathing, dressing, grooming, dental, toileting, transfer and mobility. The Administrator stated (R1) is a fall risk with the diagnosis of Dementia and their care plan has a minimum assistance with "mobility" since they walk. The family member stated (R1) walks independently and quickly throughout the building and their falls have recently stopped. The family member was not aware of a recent medication change, helping (R1) to sleep better during the night. LPA observed (R1) to ambulate, on 2/6/25, without any assistance. Based on information obtained, the above allegation is found 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. Allegation: Licensee does not provide residents with quality food service. The allegation states the food is not tasty or desirable, and the facility serves mostly junk food that looks cheap and is unhealthy. LPA toured the kitchen and observed the food being prepared as well as the food in the refrigerator and freezer on 10/21/24 (11:25 am ). LPA observed a large pot of zucchini/spaghetti and bell pepper added to the ground beef. LPA observe many loaves of multi grain bread, and abundant fresh produce, including salad mixes and bell peppers in the refrigerator and also many bags/boxes of frozen vegetables. Copy of menu was posted in the kitchen. On 1/29/25 (11:45 am): LPA observed the kitchen at 11:45 am. Both culinary staff were present (seasoned staff). LPA observed the refrigerator to be full with milk, eggs, cheese and produce and the freezer to contain meat and vegetables, in the original container/box. On 10/21/24 ( 12:25 pm) . Observed staff to have recently served lunch and residents to be eating their lunches at the tables. (2) residents had pureed food. All other resident plates had spaghetti, zucchini and garlic bread and appeared to be balanced. Good sized portions were observed also. On 1/29/25, LPA observed residents seated for lunch in each of (2) dining rooms. Food was being served around 12:15 pm in the north dining room and at 12:20 pm in the south dining room. Lunch consisted of baked chicken, rice, zucchini and a roll. LPA observed residents to be eating the food and one resident stated it was ''tasty". Residents’ were given portions to fill most of a standard size plate. *cont on 9099A-C-4.. 9099A-C-4... Allegation: Licensee does not provide residents with quality food service. The allegation states the food is not tasty or desirable, and the facility serves mostly junk food that looks cheap and is unhealthy. LPA toured the kitchen and observed the food being prepared as well as the food in the refrigerator and freezer on 10/21/24 ( 11:25 am) . LPA observed a large pot of zucchini/spaghetti and bell pepper added to the ground beef. LPA observe many loaves of multi grain bread, and abundant fresh produce, including salad mixes and bell peppers in the refrigerator and also many bags/boxes of frozen vegetables. Copy of menu was posted in the kitchen. On 1/29/25 (11:45 am), both culinary staff were present. LPA observed the refrigerator to be full with milk, eggs, cheese and produce and the freezer to contain meat and vegetables, in the original container/box. Another delivery would be made on Saturday, 2/1/25. On 10/21/24 (12:25 pm) Observed staff to have recently served lunch and residents to be eating their lunches at the tables. (2) residents had pureed food. All other resident plates had spaghetti, zucchini and garlic bread. Good sized portions were observed also. On 1/29/25, LPA observed residents seated for lunch in each of (2) dining rooms. Food was being served around 12:15 pm in the north dining room and at 12:20 pm in the south dining room. Lunch consisted of baked chicken, rice, zucchini and a roll. LPA observed residents to be eating the food and one resident stated it was ''tasty". Residents’ were given portions to fill most of a standard size plate. LPA reviewed multiple pages of food orders from an outside food service company for orders delivered on 10/5/24 and on 10/19/24. LPA observed a variety of foods ordered that were seen in the refrigerator and listed on the menu. Weekly menus were also reviewed for weeks of 9/30/24- 11/3/24. Each meal reflected a balanced diet, with a fruit and/or vegetable, included. A family member stated in January 2025 that the food had improved lately and is better tasting. Based on information obtained, the above allegation is found 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.