complaint·January 10, 2025

A review of resident #1 (R1) Resident Activities of Daily Living (ADL) Log Sheet revealed that during 5/19/24- 6/15/24, R1 weighed 92-93lbs and that ADL’s were being provided. The investigation revealed that staff used butt paste to prevent a pressure injury for R1 and interviews conducted on 6/24/24 indicate residents are receiving assistance with ADLs. The preponderance of evidence has not been met. Regarding allegation, “Staff are not meeting resident's hygiene needs” R1 Responsible Party stated that R1s teeth are never brushed. R3 Responsible Party stated a few times R3 was not smelling well upon arrival for a visit, but staff handled it. R4 stated I take care of my own as much as I can until I can't. R5 was interviewed but may not be a credible witness due to diagnosis of dementia S1 Traci stated one of the residents does hit and showers has been skipped until we can do it. R1 had a sore but cream was used on it, and R1 has dentures. S2 stated residents are on a schedule and teeth and dentures are not dirty nor neglected. S3 stated there is a shower schedule for everyone and after they get lotion. A review of resident #1 (R1) Resident Activities of Daily Living Log Sheet revealed that during 5/19/24- 6/15/24, R1 received assistance with care needs such as oral, food, liquids, shower. LPA observed on the log indicates that there were only a few instances where R1 did not either have a bowel, shower, or oral care. R1 had a dedicated shower day on Tuesday and Saturday. The investigation revealed that there is 1-2 staff on every shift and daily logs are being completed as to the hygiene practices in which staff is assisting. Interviews conducted on 6/24/24 indicate residents are receiving assistance with hygiene needs. The preponderance of evidence has not been met. Regarding allegation, “Staff are not meeting resident's nutritional needs” R1 Responsible Party stated that snacks are given. R3 Responsible Party stated that they would eat the food because it passed the taste test, and R3 loves it.R3 Rp not aware. R4 stated the food is edible and I like it. Its much better than the last place. R5 was interviewed but may not be a credible witness due to diagnosis of dementia S1 stated the food is made somewhere else and we add things like rice and vegetables. They make the main meal we add the sides. S2 stated food is cooked fresh. The food has been observed during preparation and cooking process and there is 1 cook. S3 stated R1 ate a lot even between meals. All the residents ate at the same time which was 5:30p A review of the meal menu for week 1-8 reveals that there is a variety of meals prepared for breakfast, lunch, and dinner The investigation revealed that meal main course is being cooked off site and the side items are being prepared at the facility. Interviews conducted on 6/24/24 indicate residents are receiving food of good quality and quality as well as snacks between meals. The preponderance of evidence has not been met. Regarding allegation, “Staff are not meeting resident's grooming needs” R1 Responsible Party stated that it appears that staff tends to residents grooming needs. R3 Rp stated there is no issue now but in 2023 it was but only that 1 time. R4 stated the food is edible and I like it. Its much better than the last place. R5 was interviewed but may not be a credible witness due to diagnosis of dementia S1 stated residents’ teeth are brushed and R1 has dentures. There is one resident who doesn’t like it much. S2 stated residents have shower schedules dressed and hair is brushed. Staff allow residents to do ADLs with assistance. When they refuse, there is an attempt to try again by another staff but never forced. Residents are not left with only a depend on without any other clothing. S3 stated teeth were cleaned and dentures were put into a cup to be cleaned. A review of resident #1 (R1) Resident Activities of Daily Living Log Sheet revealed that during 5/19/24- 6/15/24, R1 received assistance with care needs and R1 had a dedicated shower day on Tuesday and Saturday. The investigation revealed that residents are receiving assistance with brushing their teeth and/or dentures when allowed by the residents. Interviews conducted on 6/24/24 and 1/10/25 indicate residents are receiving assistance with ADLs. The preponderance of evidence has not been met. Based on interviews conducted on 6/24/24 and records review, it was determined that the preponderance of evidence standard is not met, therefore the allegation is UNSUBSTANTIATED. A finding of 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 incident occurred. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. Exit interview held. A copy of todays’ report provided.