complaint·July 21, 2021

On the allegation: Lack of supervision resulting in a resident sustaining injury from multiple falls. LPA De Leon conducted interviews with staff and witnesses which revealed that Resident 1 (R1) did have witnessed and unwitnessed falls. R1 was not paying for additional services for the facility to provide R1 with one on one care by facility staff. According to interviews with Witness 1 (W1) and Witness 2 (W2) R1 fell even when visitors and private care staff were present in the room and pull cords were used to notify staff. Staff response to R1’s room according to records on 10/31/2021 was at 4:03pm cleared in 11 minutes and at 5:56pm cleared in 2 minutes. The facility did submit incident reports for R1’s falls to Community Care Licensing (CCL) as required. According to interviews, pull cord records, and facility incident reports, the facility answered alarms on pull cords, called 911 when needed and followed instructions given, therefore the allegation is deemed unsubstantiated at this time. On the allegation: Staff is not responding promptly to residents’ alerts. LPA De Leon interviewed staff and witnesses which revealed that many of the residents did use the pull cords for help. According to W2 interview R1 was not able to pull the pull cord for help on own and W2 was present in the room and used the pull cord to get help from staffing. Record review showed two pull cords for R1 in 10/31/2021, one call was answered in 2 minutes and 1 call was answered in 11 minutes, according to the pull cord alarm records staff did have about 5 calls around the same time and helped residents as soon as they could. The pull cord records were reviewed, and most calls were answered within 10 minutes. Record review only showed 10 out of 160 pulls cord calls from 10/31/2021-11/09/2021 in the memory care unit to be longer than 10 minutes. Staff (S1-S4) interviews revealed that calls are answered in 10 minutes or less, some calls may take longer due to staff assisting with other residents but staff do try to finish up and get to the next call as quickly as they can and pull cord alarms notify other personal when it is not answered timely so others can assist. Based on record review the allegation is deemed unsubstantiated at this time. On the allegation: Resident was able to wander from the facility. LPA De Leon interviewed staff and witnesses no interviews revealed of any of the MC residents wandering away from the facility. LPA reviewed incident reports for this facility and observed no incident reports about a resident wandering away from the facility on 10/31/2021. The memory care unit has delayed egress with alarms that sound. Staff are trained to respond immediately if the delayed egress alarms sound. The interviews with staff or residents did not provide any evidence that this allegation occurred therefore, this allegation is deemed unsubstantiated at this time. Exit interview conducted, copy of report emailed to Administrator. On the allegation: Staff was not providing services noted for resident. LPA conducted interviews with several witnesses which revealed residents where not getting showered according to their contracts and shower schedules. The memory care unit (MC) had 18 residents at that time and facility admission agreements covered 1 shower per week and according to Witnesses 1-6 (W1-W6) those showers were not being provided according to contract and shower schedule. W1-W2 paid the facility additional care fees to provide showers 7x a week and those showers where not being provided to R1 on a regular basis. W1-W2 provided contact information to facility in case R1 refused showers to notify W1-W2 so they could come to the facility and help with facilitating a shower for R1, W1-W2 were not being notified of shower refusals. W2 asked to review the shower scheduled after arriving and resident did not look showered, smelled, hair was greasy, and clothes were dirty. Shower schedule stated the resident had been showered and signed off, but W2 had observed the resident did not appear to have been showered that day at all, hair was greasy, not combed and clothes were dirty. W2 discussed this with MC head nursing Staff 5 (S5) to show the schedule was incorrect and R1 clearly did not take a shower that day. W1-W6 stated residents did not look showered, hair was not being brushed or washed, oral hygiene was not being provided, and residents were not wearing clean clothes. LPA made 3 requests to the facility for a copy of the resident’s shower schedule/refusal records and the facility was unable to provide those records to LPA, therefore this allegation is deemed substantiated at this time. Exit interview conducted, deficiency cited, copy of report and appeal rights emailed to Administrator.