Complaint·December 20, 2023

sometimes residents think they used their call button but they did not actually press it hard or long enough to call for staff. Staff stated they also have alarms in their rooms or bathrooms they can pull. Staff also stated on occasion it can take them a while to answer the door if everyone is busy helping residents with care. LPA reviewed call button logs for 5/28/2021 through 7/16/2021. LPA observed numerous calls buttons that were responded to after 20 minutes. LPA reviewed the call button logs for R1 for a two-week period from 6/1/2021 to 6/15/2021 and observed that R1 frequently used their call button, up to several times per day. LPA observed for the two-week period, there were 20 calls between 21-30 minutes response time, 10 calls between 31-40 minute response time, 4 calls with a 41-50 minute response time, 1 call with a 51-60 minute response time, and 2 calls over 60 minutes response time. Based on the information obtained, the allegation is deemed Substantiated at this time. The following deficiencies were observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were issued at the time of the visit. and care is always prioritized. Staff stated R1 had a slip and fall during a shower on the morning shift. Ever since then, R1 was a “little more afraid” or “guarded” when it came to showers. LPA reviewed shift notes on 6/16/2021 that indicate R1 showered, fell, and the fire department responded but R1 was ok. LPA reviewed shift notes on 6/19/2021 that indicated R1 refused to shower due to the fall. LPA reviewed shift notes that indicate R1 fell in the shower on 6/23/2021. R1’s physical therapist trained all shifts on how to assist R1 but staff stated R1 was still afraid to shower. This was confirmed by notes from home health occupational therapist (OT) dated 6/24/2021, the OT discussed safe transfers and the notes recommended toilet aid for toileting hygiene, and stated on the next visit they would train facility staff on showers using the shower chair. Notes from home health OT on 7/1/2021 indicate they trained caregivers and a family member on the resident using a commode. Notes from home health OT on 7/7/2021 indicates they tried a shower chair, but R1 felt the shower chair was not safe and states to continue with commode or bed bath. Staff stated though some residents require 1 person transfer assist, they had no residents at the time who were solely 2-person transfer assists. Staff stated R1 would confuse staff and call them by the wrong names. LPA observed staff schedules for June and July 2021. LPA observed one med tech and two caregivers on the AM shift, one med tech and two caregivers on the PM shift, and one med tech and one caregiver on the NOC shift. LPA observed edits made in pen to the schedule, including adding agency staff as needed. Based on the information obtained, the allegations are deemed Unsubstantiated at this time. On the allegation: Staff handle resident in a rough manner. It was alleged that one staff handled residents roughly when assisting residents. Staff interviews stated they had not witnessed any rough handling or heard of it. Staff also stated they had not heard of it from any families/visitors. Staff stated they never heard R1 complain about staff handling them roughly or treating them without dignity. During LPA’s visits to the facility on 7/16/2021 between 12:10 pm and 5:40 pm, on 9/29/2021 between 11:20 am and 1:20 pm, on 10/20/2022 between 2:00 pm and 3:30 pm, and on 11/20/2023 between 9:30 am and 3:30 pm, LPA did not observe any staff handle residents roughly or act inappropriately. LPA interviewed Administrator about staff performance in 2021, and no staff were subject to disciplinary action based on rough handling or inappropriate interactions with residents. LPA interviewed residents who indicated there were no concerns with the care provided by facility staff. Based on the information obtained, the allegations are deemed Unsubstantiated at this time. Please continue to 9099-C, Pg 3. On the allegation: Resident is not accorded dignity in relationships with staff. It was alleged that facility staff made a resident who was not incontinent wear diapers because they could not respond fast enough to assist them to the restroom due to a lack of staffing. It was also alleged that on one occasion a staff refused to help a resident to the restroom. R1’s physician’s report dated 5/17/2021 does not indicate any bladder or bowel impairment. However, R1’s preadmission appraisal dated 6/2/2021 indicates R1 needs prompting to toilet regularly and is “usually” not incontinent. R1’s appraisal, needs and services plan indicates R1 needs assistance toileting and needs assistance with products such as briefs and pulls ups. Staff interviewed stated they were not aware of any incidents where residents’ personal rights were violated. Multiple staff indicated if they witnessed something inappropriate, they would not hesitate to call the other staff out or escalate the issue. Staff indicated Resident 1 (R1) was incontinent for the most part, and therefore it was appropriate that R1 to wear diapers. Staff indicated R1 always wore a pull up in case they had an accident, but often wore briefs due to their needs. R1’s admission agreement has an addendum indicating incontinent services and supplies were added to their fee starting 7/1/2021. Staff stated R1 improved due to physical therapy. Staff stated they never heard R1 complain about staff not treating them with dignity. Based on the information obtained, the allegations are deemed Unsubstantiated at this time. On the allegation: Facility failed to safeguard belongings. It was alleged that the remote control to a resident’s mechanical bed was missing, and reporting party believed it could have been stolen by a staff. Staff stated residents have the inventory form for their personal belongings. Staff stated sometimes residents have lost hearing aids in the past. Staff stated the family is notified as soon as they find out something is missing. Families are told up front to limit expensive items brought into the facility. The facility has replaced missing items before, such as pajamas or pants, and have been offered reimbursement or credit on their fees. LPA reviewed R1’s Resident Personal Property and Valuables form signed by R1’s responsible party. The form is crossed out and “N/A” is written in the area to list personal property/valuables entrusted to the facility. Based on the information obtained, the allegations are deemed Unsubstantiated at this time. Exit interview conducted. Copy of report issued at the time of the visit.