Complaint·June 21, 2022

Regarding the allegation that resident sustained pressure injuries while in care, according to the complainant, R1 developed bed sores the same week of the incident that had occurred on January 7, 2022 because R1 was incontinent. In addition, complainant indicated that the Administrator stated R1 had a rash, not a bedsore. During the investigation, it was acknowledged by interviewed staff that R1 laid in bed most of the time from being in pain. However, staff indicated that there was no record of any pressure injuries sustained by R1 during the time at the facility. Therefore, based on the information collected, and interviews conducted, the allegation that resident sustained pressure injury(ies) while in care is UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred. Regarding the allegation that facility refused to return resident’s belongings, according to the complainant, R1’s occupational therapist ordered DME supplies for him/her which included: a walker, a bedside commode, a wheelchair with a gel cushion. When R1’s responsible party was planning to transfer R1 to a new facility, they were going to take the supplies, however, the staff insisted the supplies belonged to the facility. During the investigation, LPA interviewed staff members and it was indicated that R1’s responsible party was trying to take the supplies but the staff wanted to keep the supplies because R1 was still a resident at the facility and the staff wanted to continue using it for R1. In addition, according the administrator, there was a misunderstanding since the facility was unaware that R1 was going to be moved to a new facility. Nevertheless, the facility did give R1's belongings to R1's responsible party when R1 left the facility. Therefore, based on the information collected, and interviews conducted, the allegation that the facility refused to return resident's belongings is UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred. Report reviewed with the Administrator, and a copy is provided with the appeals rights is provided. Regarding the allegation that the facility is not assisting resident with incontinence care, according to the complainant, R1 gets changed 2x a day, during the morning and at night. During the investigation, LPA reviewed R1’s file and it was indicated that R1 was incontinent and needed max assist with toileting needs. According to interviewed staff, it was indicated that R1 would get changed 2-3x a day. In addition, the administrator indicated that there was no care plan for R1’s toileting needs and that the facility tried to change R1 when he/she was wet. Based on the documents reviewed and the interviews conducted, it was determined that the facility is not assisting resident with incontinence care. The preponderance of evidence standard has been met; therefore, the above allegation is determined to be Substantiated. Regarding the allegation that the staff are using resident’s supplies on other residents, according to the complainant, the home health nurse ordered wound are supplies for R1. The complainant indicated that the box of supplies were open and the administrator admitted to using the supplies on other residents. During the investigation, LPA interviewed the administrator and the administrator indicated that R1 had a rash and she had used another resident’s supplies because she was waiting for R1’s supply package to get delivered. Although the administrator didn’t admit to using R1’s supplies on another resident, she did admit to using another resident’s supplies on R1. Based on the interviews conducted, it was determined that the facility staff are using resident’s supplies on other residents. The preponderance of evidence standard has been met; therefore, the above allegation is determined to be Substantiated. Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 9099D. Failure to correct the deficiencies may result in civil penalties. Report reviewed with the administrator, and a copy is provided with the appeals rights is provided.