Complaint·July 18, 2023

(continue from LIC9099) It was indicated that R1 was having problems chewing and swallowing the meal because the ‘hotdog’ meat was causing R1 to choke. A review of outside source evidence submitted during the investigation and multiple interviews with staff confirmed the incident. A review of R1’s medical records disclosed that R1 was diagnosed with Alzheimer's dementia. In addition, a review of the care plan indicated that on December 9, 2022, R1’s physician ordered a change in diet to mechanical soft food because R1 had increased restlessness and difficulties swallowing. During an interview, S1 indicated that they had fed R1 “hotdog” meat successfully in the past and assumed it was safe. According to management, staff were allowed to purchase and store their own food at the facility, as long as it was kept separately. In addition, management indicated that “hotdog” meat was not part of the regular menu and should not have been served to the residents. A review of the menu for April and May 2023, did not disclose “hotdog” meat as a meal option. After the incident with R1, management provided additional training in food service and reminded staff to adhere to the menu meal options. As part of the training, the residents’ care plans were also reviewed with all staff to ensure residents’ dietary needs were met. It was also alleged that R1’s hygiene needs were not met. It was specifically alleged that on or about April 4, 2023, R1 was observed with feces under their fingernails. According to outside sources, this concern had been addressed with facility management on at least one other occasion when R1 first moved into the facility in February 2022. A review of outside source records submitted during the investigation and multiple interviews with staff and outside sources confirmed R1 had a condition known as Scatolia (fecal digging and smearing, a common condition with dementia patients). R1’s hygiene care plan required R1’s hands to be thoroughly washed and brushed underneath the nails as part of regular incontinence care. Facility management acknowledged that the incident occurred despite their effort to meet R1’s hygiene needs. After the incident occurred, facility management reminded staff and provided additional training to ensure R1’s hygiene needs continued to be met. In addition, facility management coordinated efforts with outside sources to ensure R1’s nails were kept trimmed. (continue on LIC9099C) Continue from LIC9099C) It was also alleged that staff did not provide quality food. It was specifically alleged that R1 would often be served the same meal multiple times on the same week and/or the same day. Outside sources indicated that on May 16, 2023, during a visit to the facility, they observed that R1 was going to have lentil soup for dinner. According to outside sources, R1 had lentil soup for lunch earlier the same day, and on May 15, 2023, R1 had lentil soup as well. On May 18, 2023, it was observed in the refrigerator a container 1/2 full with lentil soup. Staff confirmed that it was left over lentil soup that had been cooked earlier in the week. A review of evidence submitted during the investigation and multiple interviews with staff and outside sources confirmed that R1 had lentil soup multiple times for two consecutive days. Multiple interviews with staff and outside sources indicated that although not standard practice, at times staff would cook large quantities of certain meals for multiple days. The Department has investigated the above-mentioned allegations and has found that there was sufficient evidence to corroborate the above allegations. Therefore, these allegations are deemed to be substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies were cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations and are listed on LIC 9099-D. A plan of corrections was developed with Administrator, Tapia. An exit interview was conducted with Caregiver, Perez and Administrator, Tapia, and a copy of this report, Confidential Name List (LIC 811), along with Licensee/Appeal Rights (LIC 9058 03/22) were provided at the conclusion of the visit. (Continue from LIC9099A) According to S2, there had been a change to increase the dosage and they were waiting for the new order to update “Synkwise” (Electronic Medication Administration Record system). However, during staff interviews, management indicated that the change in medication caused confusion among the staff, but that the medication continued to be administered as prescribed. When the new order came in it was immediately updated in Synkwise. A review of medication records for the April and May 2023 periods indicated the medication was an active medication. However, there were multiple dates with missing recordings. The staff involved, S2, indicated that they had administered the medication as prescribed, but had failed to record it on Synkwise. During regular medication records review, there was no unaccounted medication. Multiple interviews with outside sources did not disclose any corroborating evidence that medication was not administered as prescribed. The Department has investigated the allegation and has found that there was insufficient evidence to corroborate the above allegation. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, this allegation is deemed to be unsubstantiated. An exit interview was conducted with Caregiver, Perez and Administrator, Tapia, and a copy of this report, Confidential Name List (LIC 811), along with Licensee/Appeal Rights (LIC 9058 03/22) were provided at the conclusion of the visit.