complaint·March 18, 2025

(Continued from LIC9099 p.1) Review of facility records revealed documentation from the facility requesting families to send additional toilet paper due to their resident running low or going through it quickly. LPA spoke with a staff member who contacted a family to bring additional toilet paper to confirm if the request was done to accommodate the rule, or if it was due to resident preference of brand. The staff member stated that they contacted the family to provide more toilet paper due to the rule of 2 rolls per week. Review of the Residence and Care Agreement revealed no documented policy informing families and residents of the 2 rolls per week rule. The agreement offers that the facility will provide, for a fee, certain personal care supplies if a resident is unable or chooses not to purchase them for themselves. However, the item of toilet paper was not found as a purchasable item from the facility. An additional document referenced in the Residence and Care Agreement pertinent to this procedure was not able to be produced by the facility. Three outside sources were contacted regarding the allegation. One outside source was not aware of any issues surrounding toilet paper at the facility. A second outside source was not able to speak to the allegation due to lack of consent from the resident in question. A third outside source confirmed the facility policy regarding 2 toilet paper rolls per week and advised they were not made aware of the rule prior to their resident moving into the facility. Regarding the allegation, "Licensee did not administer medication as prescribed", the accuracy of R1's medication administration by the facility was brought into question, and that the facility cancelled an eye drop prescription for R1 outside of the doctor's order. Staff members interviewed did not have knowledge of any medication errors for R1, however, the Medication Administration Record during the timeframe of the complaint showed that a PM medication administration was not given on 04/11/2024. No records were found to explain the missing administration, such as documentation error or resident refusal. Review of facility records revealed that the facility received an order from R1's doctor to discontinue an eye drop medication on 04/17/23. Additional records showed that the existing supply for the medication was discarded due to being expired. No evidence was found to support that R1's prescription was discontinued by the facility outside of the physician's order, or that a medication error existed with the eye drops. An outside source familiar with the issue was not able to speak to the allegation due to lack of consent from the resident. R1 was not able to be interviewed due to no longer living at the facility. Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violations 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 Angela Scott-Kapiloff, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided (Continued from LIC9099 p.1) Staff informed of a laundry basket in R1's room that was made of a natural material that began to harbor mold. Staff informed that R1's responsible party was notified and requested to replace the basket with a new one. Records review revealed a contractor invoice during the timeframe of complaint to replace the flooring in question. This corroborated staff statements that the facility was in the process of correcting the issue. Facility records were found regarding staff member communication with R1's responsible party, requesting for a new laundry basket to replace the old one due to mold on the bottom. This corroborated staff statements that attempts were made to correct the issue. An outside source familiar with the situation was not able to speak to the allegation due to lack of consent from the resident. During an unannounced facility visit LPA directly observed the flooring in question. The bathroom floor had dark brown/black discoloration under the seam that connected the shower to the vinyl flooring. The flooring was observed to be separating and curling up, away from the base. The substance was not fuzzy in texture and did not wipe off when touched. No evidence was found to show that the substance was tested or identified as mold. The laundry basket in question was no longer present in the room upon notification of potential mold on the bottom and was not able to be inspected by LPA. LPA directly observed the new flooring planks to replace the old flooring in the Memory Care section of the facility, corroborating staff statements and records that the facility was in the process of correcting the flooring. Regarding the allegation, "Licensee did not address air conditioner in disrepair", it was alleged that the facility did not take action regarding R1's air conditioning system not working. Staff interviews were mixed regarding this situation. Some staff were aware that it had broken but stated it was fixed, and other staff did not have knowledge of any air conditioning issues. Management informed that the facility had attempted to fix the air conditioning and that R1 was provided a fan and eventually moved to a different room, partially due to the ongoing air conditioning and bathroom floor issues. Review of facility records revealed an invoice from an HVAC specialist for R1's room during the timeframe of complaint. The invoice was approved by management to conduct the recommended work. Additional facility records showed that maintenance was called to fix R1's air conditioner on a different date during the timeframe of complaint and it began working again. (Continued on LIC9099-C p.3) (Continued from LIC9099-C p.2) Additional records showed communication between the facility and R1's responsible party confirming that a contractor was scheduled to fix R1's air conditioner during the timeframe of complaint. Facility records also corroborated the information regarding R1 being moved to a different room in the facility that did not have air conditioning issues. Outside source interviews were mixed regarding the allegation. One outside source advised that the air conditioner worked each time they assisted R1, with no issues. A second outside source familiar with the situation was not able to speak to the allegation due to lack of consent from the resident. LPA directly observed the air conditioner in question during an unannounced facility visit. The air conditioner did not turn on when prompted, however, R1 had already been living in a different room and subsequently moved out of the facility prior to this visit. No resident was living in the room during this visit and repairs were scheduled prior to a new resident moving in. The air conditioner did turn on and worked properly in the room that R1 had moved to, prior to moving out of the facility. Regarding the allegation, "Licensee did not follow resident's Admission Agreement", it was alleged that the Licensee did not provide the agreed upon laundry service and shower assistance to R1, per the admission agreement. Staff interviews revealed that during the timeframe of complaint, caregivers, Med Techs, and housekeeping were washing resident laundry per the laundry schedule for Memory Care residents. Staff members consistently confirmed during interviews that there were no issues with laundry service and resident laundry was being washed according to the schedule and each resident's admission agreement. Staff informed that R1 was mostly independent regarding showers, requiring reminders only, which staff conducted. Staff interviews revealed that the need for R1's care level to increase existed in order to provide additional support for showers. Review of facility records revealed communication between the facility and R1's responsible party regarding R1 declining to take showers. The communication showed suggestions for how to help R1 shower more frequently. Records review also revealed that R1's laundry was scheduled to be completed on Wednesdays, when their room was cleaned. Review of communication logs showed that staff washed R1's laundry and communicated the need for a new laundry basket due to moisture and mold collecting on the bottom. No record evidence was found to show that R1's laundry was not being washed per the laundry schedule and R1's admissions agreement. (Continued on LIC9099-C p.4) (Continued from LIC9099-C p.3) An outside source familiar with the allegation was not able to speak to the situation due to lack of consent from the resident. Regarding the allegation, "Licensee did not ensure provision of hygiene products", it was alleged that when R1 was moved into a substitute room at the facility, the Licensee did not move their belongings into the new room, resulting in R1 not being able to wash their hands, shower, or change their clothing for 15 days. Staff interviews did not corroborate the allegation, as staff informed that R1's belongings were initially moved into the new bedroom. Staff informed that the logistics of R1's move became confused due to the moving company rescheduling, and an internal communication issue resulted in some of R1's belongings being brought back to the former room, as a staff member believed the move was temporary. Records review corroborated staff statements, revealing that some of R1's items were moved back to the former room in error, however, the records showed that R1's belongings were initially moved into the new room. Narrative Charting notes during the timeframe of concern corroborated staff statements that the timing of R1's move was adjusted due to the moving company not being able to assist on the originally scheduled date. Narrative Charting notes also revealed that once R1's items were moved into the new room, staff attempted multiple times to help R1 unpack their belongings, however, R1 refused stating that they would get the items as they needed them. This resulted in R1's belongings remaining in boxes in their new room. Outside source records and facility records additionally revealed that R1 was able to shower on their own independently and have access to their personal care supplies. Records showed that R1 struggled with taking consistent showers and would refuse to take them for periods of time. Additionally, records showed a potential concern of R1 removing the clothing needing to be washed from their laundry basket and attempting to wear it. Narrative charting notes and Medical Administration Records revealed that although R1 was primarily independent, staff interaction occurred during each medication pass and also during mealtimes. No records were found to indicate that R1 was ignored by staff or not checked on for 15 days straight. An outside source familiar with the situation was not able to speak to the allegation due to lack of consent from the resident. (Continued on LIC9099-C p.5) (Continued from LIC9099-C p.4) While the evidence shows that confusion with the logistics of R1's move existed, evidence was not found to clearly show the frequency of R1's showers, hand-washing, or changing of clothes. Evidence does show that staff attempted to assist R1 during the transition of the move and R1 had a pattern of refusing help and refusing to change clothing and shower. R1 was not able to be interviewed regarding the allegations due to no longer living at the facility. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Executive Director Angela Scott-Kapiloff, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.