Complaint·March 10, 2022

LPA also requested copies of documents pertaining to the investigation. On 03/02/2022, from 2:00pm to 4:20pm, (LPA) Kontilis conducted a subsequent complaint visit to the facility and met with Miriam Santiago, Interim Administrator and Business Office Manager. LPA obtained documents pertaining to the above-stated allegations and conducted interviews from 2:00pm to 4:10pm. LPA Kontilis conducted interviews with the complainant on 05/01/2020 and 05/05/2020; with staff on 05/04/2020 at approximately 4:55pm, on 03/02/2022 at approximately 11:36am to 2:10pm, and on 03/04/2022 at approximately 11:19am. On 04/15/2020, Resident #1 (R1) was admitted to the facility. R1’s Physician Report, signed 04/14/2020 by Dr. Winner, listed the diagnosis as AFib, HTN, hyperlipidemia, anxiety and dementia. Additional conditions included aggressive, inappropriate, wandering, sundowning behaviors, confused and disoriented. R1’s ability to communicate needs and feed self was listed as borderline. On the allegation: Resident assaulted other resident(s) in care. On 04/25/2020, at approximately 9:45am, R1 became aggressive and began flipping over tables, chairs and planted pots in the dining room and courtyard. Staff and residents were present during the incident and reported being pushed or hit by R1’s actions. Staff called 911, and Santa Barbara City Police arrived and assessed R1. R1 exhibited increased agitation and police subdued resident handcuffed on the ground. Once R1 was calm, the med tech was able to provide R1 their prescribed PRN for anxiety. On 04/26/2020, at approximately 6:30am, R1 approached staff and requested a shower. Staff escorted R1 to the shower when R1 pushed staff. Staff moved away from R1 to give space, R1’s agitation increased and began banging on the med room window. R1 then went to the outdoor courtyard and attempted to jump over the gate. Staff was able to redirect resident back inside. Staff called 911, and Santa Barbara City Police arrived and assessed R1. On both dates, police stated they were unable to take R1 via 5150 and the facility was instructed to call the crisis hotline prior to calling 911 for 5150 situations. On 04/27/2020, the Executive Director contacted R1’s physician to request a medication evaluation for R1 and the PRN medication order was changed to routine. Staff received an in-service training regarding the protocol for future incidents and were instructed to call crisis hotline to request paramedics instead of police officers so that the mobile crisis unit could intervene. A review of the April 2020 staff schedule and statements from management and staff interviews revealed that at the time R1 was admitted to the facility on 04/15/2020, there was not an adequate amount of staff to provide the proper care and supervision to R1. Based on the information obtained, the allegation is deemed substantiated at this time. On the allegation: Facility is not adequately staffed to meet residents’ needs. A review of the April 2020 resident roster found that there were thirteen (13) residents, of which six (6) were on hospice. All residents had a diagnosis of dementia. Five (5) residents required a two (2) person assist, two (2) residents required a Hoyer lift for transfers, eight (8) residents required a one (1 ) person assist with activities of daily living, and four (4) residents required feeding assistance. The staff schedule for April 2020 reflected there was one (1) caregiver and one (1) med tech on the a.m. shift and the p.m. shift, and two (2) caregivers on the overnight shift. Information obtained through interviews found that the caregivers also had to perform housekeeping and laundry duties. Management and staff interviews revealed that there was not an adequate amount of staff and that the staffing budget had been cut by corporate due to the low amount of admissions to the facility. Interviews also revealed that at times there were no staff present with the residents in the dining and common areas due to staff were attending to other residents in their rooms. Based on the information obtained, the allegation is deemed substantiated at this time. Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued. LPA also requested copies of documents pertaining to the investigation. On 03/02/2022, from 2:00pm to 4:20pm, (LPA) Kontilis conducted a subsequent complaint visit to the facility and met with Miriam Santiago, Interim Administrator and Business Office Manager. LPA obtained documents pertaining to the above-stated allegations and conducted interviews from 2:00pm to 4:10pm. LPA Kontilis conducted interviews with the complainant on 05/01/2020 and 05/05/2020; with staff on 05/04/2020 at approximately 4:55pm, on 03/02/2022 at approximately 11:36am to 2:10pm, and on 03/04/2022 at approximately 11:19am. On 04/15/2020, Resident #1 (R1) was admitted to the facility. R1’s Physician Report, signed 04/14/2020 by Dr. Winner, listed the diagnosis as AFib, HTN, hyperlipidemia, anxiety and dementia. Additional conditions included aggressive, inappropriate, wandering, sundowning behaviors, confused and disoriented. R1’s ability to communicate needs and feed self was listed as borderline. On the allegation: Staff not following resident admission procedures. Copies of admission paperwork for R1 were obtained and reviewed. R1’s Resident Assessment is dated 04/14/2020; the following forms were dated 4/15/2020 and signed by R1’s representative and Mary Moore, Executive Director: Pre-Placement Appraisal; Financial/Responsibility Form; Admission Agreement; Physician Report; tb clearance; Sansum Clinic medication list; I.D. and Emergency form; and Needs and Services Plan. Based on the information obtained, the allegation is deemed unsubstantiated at this time. Exit interview conducted, appeal rights and a copy of this report issued.