complaint·November 6, 2023

(Continued from LIC9099) Records review did not corroborate the allegation, and confirmed that residents exhibiting aggression and/or distress were given PRN medications according to their prescriptions. Resident interviews were not possible due to impaired cognition. LPA observations revealed staff members assisting residents with Activities of Daily Living (ADLs) and redirecting them as necessary. Regarding the allegation, "Licensee did not ensure resident(s) had access to personal care supplies", it was alleged that the Licensee did not ensure protocols were in place for resident personal care supplies to be maintained. Staff interview did not corroborate the allegation, as staff interviewed exhibited knowledge of the Responsible Party notification process when additional care supplies were needed. Records review revealed that the expectation was for residents and/or their Responsible Parties to provide personal care and hygiene supplies, with an agreed-upon option to pay an additional fee if they preferred the facility to provide these items. LPA observations revealed that the facility has had an emergency stock of personal care supplies, including briefs and incontinence supplies, if a resident ran out before their Responsible Party could bring more. Based on interviews, observations and records review, a preponderance of evidence does not exist to prove that the alleged violation(s) occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Executive Director Stefanie Ancheta, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. (Continued from LIC9099) Outside source interviews corroborated the allegation, revealing that a staff member exhibited impatience for a resident and spoke about them to others in a way that was disrespectful to the resident. Records review also corroborated this allegation, showing that the staff member in question (S2) was terminated due to inappropriate conduct toward residents and staff. Staff interviews corroborated that staff were instructed to provoke a resident. Regarding the allegation, "Staff did not meet resident(s) incontinence needs", it was alleged that staff did not assist residents timely with their incontinence needs. Staff interview revealed that staffing levels were low during the timeframe of the complaint, resulting in staff not being able to assist residents immediately when they had incontinence needs. Outside source interview revealed that residents were left in saturated briefs for long periods of time without being assisted and the resident floors had a strong smell of urine. Resident interview corroborated that night staff did not assist residents with incontinence care. During an unannounced facility visit on 2/22/23 LPA directly observed residents walking around with soiled briefs and a strong odor in the facility of incontinence. Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violation(s) occurred and are therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Executive Director Stefanie Ancheta, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.