complaint·February 5, 2024

The hospital evaluated that R1 had mild erythema of an old chest scar that seemed to be very mild cellulitis. Also, R1 was diagnosed with a diffuse nonspecific rash that could be bed bugs versus nonspecific dermatitis. R1 was prescribed medications for the itch/bites. Staff interviews stated they provided R1 with dressing and showers but did not observe any bites on R1 on 01/05/24, 01/06/24, or 01/07/24. However, staff reported R1 was constantly itching and scratching their body. The administrator did not observe the bites or was notified by staff, as they were out on vacation during that period. It was also alleged staff did not address bed bug infestation. On 01/06/24, when R1 was transported to the hospital for a possible chest infection, it was identified that R1 was covered in bug bites. R1’s responsible party reported the bites to the licensee. On 01/09/24, R1’s responsible party and an outside source witnessed bed bugs on R1’s bed. On 01/09/24 R1’s mattress and recliner were disposed of. The staff stated they used Clorox wipes to wipe down R1’s furniture and washed the clothing R1 was wearing in bleach. Staff confirmed R1’s clothing in their drawers was not bagged up or washed in heat. Staff were not aware of universal precautions regarding bed bugs. The licensee stated a professional pest control company came to the facility on 01/10/24 and did not observe bed bugs. The pest control company documented on 01/10/24, no live activity or evidence of activity was seen; mattresses and other bed clothing were already discarded, and inspected area cleaned out, before visual inspection. The licensee’s interview revealed he did not witness bed bugs. However, R1’s items were already disposed of prior to licensee’s inspection on 01/10/24. It was also alleged the staff did not ensure R1’s call pendant was working. The administrator stated R1 throws their call button, and it breaks. R1 was given three (3) call buttons and destroyed all of them. Staff interviews indicated R1’s mental condition inhibits R1 from using the call button. Outside source interviews revealed when R1 had a call button but it did not work, as the outside source would push the button to try and alert staff but there was no response. R1’s responsible party also attempted to activate the call button on numerous occasions and did not work to alert staff. The administrator was not aware the call button was not operating, as it was not brought to her attention. It’s possible the button was broken due to R1 throwing it. However, staff did not ensure R1 was afforded the call button for assistance. Staff mentioned they observed the call button hanging from R1’s nightstand but also not aware the button was not working. Staff also stated they do not check or monitor the call buttons for residents. The facility is required to have a signal system as outlined in Title 22 Regulation, which shall operate from each resident's living unit. On 01/17/24, LPA toured R1’s bedroom and did not observe a call button. Continued on an LIC 9099C. Further staff interviews revealed the last time they observed the call button was approximately one (1) week prior to LPAs visit. Staff did not alert the administrator that R1’s call button was not working or present in their room. Based on LPA’s observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Administrator, Tess Derafera whose signature below confirms receipt of these rights. The facility provided the following services to R1, bathing, grooming/dressing, help moving about the facility, eating, medications, and toileting as R1 was incontinent of both bowel and bladder. Staff interviews confirmed R1 was verbally abusive and violent, causing injury to staff. On 01/08/24, R1’s family member observed R1 calling for help as they already had bowel movement and smeared feces on their bed, and walls. R1 was identified with a medical condition that had R1 reach into their diaper after defecating and used their hand to smear the feces on themselves and items. Staff interviews confirmed R1 will reach into their diaper and smear their feces. Further staff interviews revealed R1 had multiple bowel movements a day, between four (4) to five (5) times a day. R1 did not have a regular bowl movement schedule, therefore, staff were unable to gauge when to the bowl movement and smearing of feces would occur. Staff stated they checked on R1 every 30 minutes. Additional staff interviews revealed they checked on R1 every two (2) hours. The administrator explained they do not provide one on one care to residents. Therefore, they cannot always know when R1 was going to have a bowel movement tin order to get to R1 prior to R1 smearing feces. Staff confirmed once observing R1 with feces, R1 was changed and showered more than their allotted shower days, which was twice a week. Staff confirmed R1 would typically receive four (4) or more showers a week due to wanting to ensure R1 was kept clean. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegation. The allegation was deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Administrator, Tess Derafera whose signature below confirms receipt of these rights.