complaint·June 17, 2024

facility provided R1’s recent history, physician’s reports, medication list, and advanced healthcare directive. However, the facility did not give a complete copy of R1’s records to their responsible party as requested. Based on the information obtained, the allegation is deemed Substantiated at this time. On the allegations: Staff did not ensure resident’s room was kept in clean sanitary conditions, and Staff did not ensure resident’s room was free of mal odors. LPA reviewed photographs obtained by Resident 1’s (R1’s) responsible party (RP). RP stated when RP visited R1 in R1’s room on 12/31/2023, feces were observed on the wall of R1’s room. RP indicated R1 had a behavior of throwing their brief at the wall. LPA observed photographs of numerous brown marks all over a wall but did not observe any during the visit on 5/21/2024. RP stated feces was observed in R1’s room on 12/31/2024 which caused a mal odor in the room. RP stated they conducted a walk through with now former Administrator on 4/23/2024 at which time RP observed the feces on the wall was “dried and still present” and stated the feces seemed to be dry enough to not present a mal odor. During the visit on 5/21/2024, LPA toured the “Compass Rose” memory care unit of the facility with Staff 1 (S1). At approximately 2:00 pm, LPA observed a mal odor in the common area of the memory care unit, of urine and feces. LPA brought the odor to S1’s attention, and S1 stated “I smell it too.” Based on interview conducted and documents obtained, the allegation that Staff did not ensure resident’s room was kept in clean sanitary conditions is deemed Substantiated at this time. On the allegation, facility staff did not safeguard resident’s personal belongings, RP stated R1 had many personal belongings such as but not limited to scarves, clothing, sheets, bedspread, a doll, and pillows. RP noted one scarf that was missing was worn by a staff member, who stated a resident gave them the scarf. RP further stated when R1’s coats, jackets, and other clothing articles were returned from being laundered, many of the items had been “ruined” due to having been put through a washer and/or dryer when they were not the type of fabrics that should have been washed and/or dried. RP provided email communications between facility staff and RP inquiring about missing and damaged items. RP also noted when R1 was moving out, RP discovered several items in R1’s room that did not belong to R1. During the visit on 5/21/2024, LPA conducted interviews with residents. Resident 2 (R2) stated their clothing and laundered items were not returned after several days. Resident 3 (R3) stated personal clothing items such as shirts were either being washed in too hot of water or dried at too hot of a temperature because the shirts are getting “shorter and shorter”. R3 also stated a furniture item was damaged when facility staff moved R3 into a different room. During today’s visit, LPA conducted an interview with R3’s Responsible Party. R3’s Please continue to 9099-C, Pg 3. Responsible Party confirmed R3’s chair was broken as a result of R3’s move. The investigation revealed that some items went missing; and also that facility staff damaged multiple items belonging to residents. Based on records reviewed and interviews conducted, the allegation “Facility staff did not safeguard resident’s personal belongings” 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. Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted. A copy of the report and appeal rights were issued at the time of the visit. residents are checked every two hours and changed as needed. Some residents noted they had difficulty communicating with the staff because they do not speak English, but they try to communicate through gestures. Technical assistance is provided to remind the licensee of their responsibility to have competent staff that can communicate appropriately with residents. Although the allegation may have occurred, there was insufficient evidence to prove it; therefore, the allegation is deemed Unsubstantiated at this time. On the allegation: Staff did not ensure medications were dispensed as prescribed to residents in care. It was alleged that staff did not provide R1 their eye drops to them as prescribed. It was alleged R1 moved out of the facility and had 3 to 5 extra bottles of eye drops. If R1 had received them as prescribed, they should not have so many extra bottles. Staff stated sometimes R1 refused the eye drops, which could account for the extra bottles over the years R1 lived at the facility, as the eye drops were auto-refilled by the pharmacy regardless if they were empty or not. LPA reviewed centrally stored medication records for the facility and medication lists that showed R1’s eye drop medications. However, R1 moved out of the facility in April 2024, and the eye drops were no longer at the facility and could not be reviewed. Based on the information obtained, there was insufficient evidence to prove the allegation occurred. Therefore it is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report issued at the time of the visit.