Complaint·September 6, 2022

On 9/01/22 at 9:50 am, LPA spoke with Witness #1 (W1). W1 states “I have never witnessed a person sleeping on the couch permanently, only a resident taking a nap.” W1 says that they spent “a lot of time in the facility.” On 9/6/22 at 10:07 am, LPA interviewed Witness #2 (W2). W2 says that they have never observed a seventh resident living in the facility. On 9/2/22, LPA reviewed resident records. Admission agreements, Register of Facility Clients/Residents (LIC 9020), and Death Reports (LIC 624A) show that the facility had six residents in September and October 2020. There were six residents in November 2020 with one resident passing away and a new resident admitted. In December 2020, there were five residents after one resident moved out. Based on the evidence obtained, the allegation “Facility over capacity” is deemed Unsubstantiated at this time. Interviews and records indicate that the facility was not over its capacity of six residents. On the allegations “Staff left resident in soiled clothing for extended period of time,” and “Staff are not meeting resident's hygienic needs,” the complainant’s concern was that residents’ diapers are only getting changed once a day, and that residents are not getting showers. LPA interviewed the licensee and witnesses, and reviewed records. On 3/03/21 at 12:13 pm, LPA interviewed the licensee. Licensee says residents’ diapers are changed “Every time there’s a bowel movement, in the am, before meals, after meals, every hour, before sleep at night.” On 3/03/21 at 1:51 pm, LPA toured the facility. At 2:03 pm, LPA observed Resident #1 (R1) sleeping in their room. There was a package of 20 diapers in R1’s bedroom closet. LPA observed Resident #2 (R2) in bed in their bedroom with 10 diapers in their bedroom closet. Resident #3 (R3) was in a recliner in their bedroom. LPA did not smell any malodors in the facility. On 9/1/22 at 2:10 pm, LPA toured the facility and did not experience any malodors. During the visit, LPA attempted to interview staff, however, they were busy changing residents’ diapers. On 9/1/22 at 9:50 am, LPA Chavez interviewed W1. W1 says that the licensee and his staff “cared with a great deal of love.” W1 says that R3 wore diapers and that towards the end of R3’s life, R3 was “difficult because R3 didn’t understand what people wanted from R3.” W1 explains that W1 was “never concerned with staff changing R3’s diapers and caring for R3.” On 9/6/22 at 10:07 am, LPA spoke with W2. W2 says the staff took very good care of their mother and that that staff “loved and cared for” their mother. W2 says “There are no problems with how staff were caring for my mother.” Continued on 9099-C On 9/1/22, LPA reviewed the facility’s “Resident Shower, Bowel, Sheet Log” for February 2021 and March 2021. Staff recorded the times they gave a resident a shower and the times they assisted with cleaning a resident after a bowel movement. The Log indicates that staff assisted residents with showers daily and bowel movements as needed. LPA reviewed the facility’s “Resident ADL (Activities of Daily Living) Sheet” for February 2021 through March 5, 2021. Staff recorded the times they assisted residents with “Incontinent care/change” and the Log lists four times a day: “AM, Lunch, 2-3 pm, and Bed.” On every day in February through March 5, 2021, residents were assisted with incontinent needs at minimum three times a day, and sometimes four times a day. Based on the evidence obtained, the allegations Staff left resident in soiled clothing for extended period of time ,” and “ Staff are not meeting resident's hygienic needs ,” are deemed Unsubstantiated at this time. Interviews and records indicate that staff were attending to residents’ hygiene needs in a timely manner. On the allegation “ Staff did not provide food to resident ,” the complainant’s concern was that “R1 is in bed all day and doesn’t get lunch because R1 is asleep.” Complainant further reports that “When R1 wakes up, R1 doesn’t get lunch.” To investigate the allegation, LPA interviewed licensee and witnesses, and reviewed records. On 3/03/21 at 12:13 pm, LPA interviewed the licensee. Licensee says residents are offered a large breakfast between 7am and 9am, a lunch between 11am and 12pm, snacks at 3 pm, and dinner between 4pm and 5pm. He explains that if a resident is asleep at lunchtime, when they wake, “they may be offered a snack instead of lunch, if they had a large breakfast.” On 3/8/21, Licensee provided to LPA a summary of care for R1. Licensee writes that R1 “has late stage progress dementia. R1 still knows their name and at times will state their needs, and most of the time will graze their breakfast taking their time to eat. R1 will usually go back for a nap after breakfast and skip most lunches, waking up for snacks and eating full dinner meals. This has been R1’s routine for the past year.” On 3/03/21 at 1:59 pm, LPA observed Resident #4 (R4) snacking at the dining table. On 9/6/22 at 10:07 am, LPA spoke with W2. W2 says that R1 was on hospice the last year and a half prior to passing. W2 describes staff as offering food to R1, but that R1 “didn’t want to eat much.” W2 explains that the hospice nurse kept track of R1’s weight, and R1’s doctor did not want staff to force feed R1. W2 says that R1 was bedridden and didn’t “expend calories.” Continued on 9099-C. On 9/6/22, LPA reviewed records. On R1’s “Resident ADL Sheet,” for February 2021 through March 5, 2021, staff recorded that percentage of food R1 ate at Breakfast, Lunch, and Dinner. With the exception of four days in February, R1 ate between 25% and 100% of R1’s meals. Based on the evidence obtained, the allegation, “Staff did not provide food to resident,” is deemed Unsubstantiated at this time. Interviews and records indicate that R1 was provided sufficient food to maintain adequate health. Exit interview conducted and the report emailed to licensee.