complaint·August 27, 2025

Staff stated sometimes the scheduled activities were offered to the residents, but not always depending on the needs of the residents throughout the day. Based on all interviews conducted and documents obtained, at this time the above allegation was found to be unsubstantiated . On allegation: Staff do not meet residents oral hygiene needs. It was alleged Resident #1's (R1’s) teeth look like they have not been brushed and their family has to help them brush their teeth. Interviews reveled R1 took care of their own oral care needs, but due to all hygiene items being locked up they had to ask staff for access to their toothpaste. On several occasions R1 was often frustrated not having access to their toothpaste and stated “it’s not like I am going to eat it”. Staff were able to provide R1 access to their toothpaste when they asked for it. Record review of R1’s LIC602A Physician’s Report dated 11/22/2024 is mark “yes” next to “at risk if allowed direct access to personal hygiene items”. Based on all interviews conducted and documents obtained, at this time the above allegation was found to be unsubstantiated . Exit interview conducted, report signed, and report provided to the Administrator. R1 resides in Compass Rose, the memory care unit. It was also alleged the facility started locking up all personal hygiene items, including hand soap and toothpaste. LPA interview with the facility Administrator on 5/22/2025 revealed that upon admission to the facility each resident and/or their responsible person are provided a list of items to bring to the facility upon admission, but if a resident runs out of their own supply the facility has a back-up supply to provide the resident that they may charge for but often do not. LPA was provided a copy of the list titled “Suggested items to bring when moving in”. Among the items listed are soap and toilet paper. The list does not note any additional cost if the facility provides the items. Review of the facility admission agreement including appendix B (Amenity Sheet, The Oaks at Paso Robles, Fees for Additional Items and Services) reveals no requirement placed on the resident or their responsible person to supply toilet paper and hand soap, or a fee when supplied by the facility. On 5/22/2025 LPA and Administrator toured the facility to observe any back-up supplies of hand soap and toilet paper for resident use. The facility keeps separate inventories of supplies in the assisted living and memory care units for budgeting purposes. At 3:36pm on the first floor in the assisted living side of the facility, LPA and Administrator observed the back-up supply of resident hand soap and toilet paper in the commercial laundry and housekeeping area for residents in the assisted living side. LPA observed the doors to the resident toilet paper supply were chain locked and staff interviews revealed they lock it because the staff from memory care were coming over and taking from the supply. LPA photographed the locked cabinet and when opened by staff 21 rolls of residential toilet paper were documented. At 3:51pm Administrator showed LPA locations where back-up hand soap and toilet paper supplies are stored in the memory care unit; a supply closet between rooms 217 & 218, a housekeeping closet near room 216, and the med-tech room. LPA and Administrator observed there to be no back-up supply of hand soap or toilet paper in these areas, LPA photographed the areas. The Administrator stated they must have overlooked ordering a supply of toilet paper for the memory care unit since they do not currently have a memory care director. Regarding R1’s personal supply being locked up, on 5/22/2025 the Administrator stated this went into effect about a week prior for resident safety, he had asked staff to lock up all liquid hygiene items, including hand soap, and R1’s toilet paper may have been locked up by accident. The Administrator stated he had not notified the responsible parties of this change and was waiting on more specifics from corporate before notifying. There is hand soap available in the public restrooms in memory care and staff are expected to remind or assist residents to wash their hands, the residents may also ask to wash their hands. (Continued on LIC9099-C) Staff interviews reveal this does not always happen and some residents in the unit are not able to ask to wash their hands but can take care of their own toileting needs. Staff also stated there have been occasions since this new policy was implemented when the public restrooms in memory care have not had hand soap for staff or residents to wash their hands and they have brought their own soap to use. On 5/28/2025, a notice was sent out to residents and their responsible person regarding the new policy. Based on the observation, interviews, and information obtained, since supplies necessary for maintenance of adequate hygiene practice were not readily available to each resident including soap and toilet paper, the allegation is deemed substantiated at this time. Exit interview conducted, deficiencies cited on the LIC9099-D page, report signed, and report provided to the Administrator.