complaint·September 28, 2023

Resident's hygiene needs not being met: On 8/19/2021, the Department interviewed R1's family member (FM). FM stated R1 was not incontinent. FM stated he/she wanted R1 to wear fresh/clean undergarments daily, so he/she brought a lot of diapers in R1's bedroom, and he/she changed R1's diaper whenever he/she met R1. FM stated most of time he/she found R1 wore soiled diaper whenever he/she visited R1. FM stated he/she found caregivers did not change R1's diaper often. FM stated the resident bedroom trash bags were changed 2 or 3 times per day, why the facility was unable to change R1's diapers at least 3 times per day. FM admitted R1 did not participate in the facility changing diaper program, because R1 did not need to change diaper every two hours. On 8/20/2021, LPA interviewed Executive Director (ED). ED stated that upon admission, residents were assessed if the residents need the toilet remind or need physical hands-on changing diaper. If there was no need for the service, then the facility will not check or change the residents diapers. ED stated if the assessment shows the resident needs the service, then the resident needs to pay either $400/month fee for toilet remind service or $900/month fee for hands on diaper changing service. ED stated the facility will check resident diaper every two hours for the services. ED stated R1 was not diagnosed as incontinent and was not evaluated as toilet reminding needed or diaper changing needed. ED stated R1 did not have toilet reminding or diaper changing in R1's care plan. ED stated caregivers provide care service according to care plan, so R1 did not receive the service of diaper changing. ED stated caregivers changed R1's soiled diaper when caregivers found R1's diapers needed to be changed. ED stated residents can participate in the toilet reminding or diaper changing programs voluntarily if they pay the fee. ED stated the facility communicated with R1's family member to have R1 participate in the changing diaper program, but R1's family disagreed to pay $900 per month. ED stated housekeepers cannot change residents' diapers. Reviewing R1's medical documents, R1 was not diagnosed incontinent and R1 was not evaluated to have toilet reminding or diaper changing service. FM found the diaper supplies he/she put in R1's bedroom decreased but did not decrease as much as expected that means caregivers changed diapers for R1 but not as often as needed. FM did not pay the monthly fee for the changing diaper program. The facility suggested R1 to participate in the changing diaper program, but FM disagreed. Continue on LIC9099-C. Page 2 of 4 Medications not given to resident according to physician's instructions: On 8/19/2021, the Department interviewed R1's family member (FM). FM stated R1 had doctor's prescription medications to be administered twice per day, but the facility administered R1's medications to R1 at 8:00AM and 4:00PM. FM stated the medications should be administered between 12 hours if the prescription specified twice per day. On 8/20/2021, LPA interviewed Director of Resident Care Service (DRS). DRS stated caregivers were not allowed to administer medications to residents; only Med Tech or Nurses can administer medications to residents. DRS stated the operation hours of the medication rooms to administer medications to residents were 6:00AM - 8:00AM and 4:00PM - 6:00PM, so the medications will be administered to residents during these time period windows except doctor prescriptions specified the time. DRS stated one of the residents had a doctor prescription specified bedtime 9:00PM, and the facility administered the medications at 9:00PM to resident. DRS stated the facility communicated with R1's family member (FM) to have the doctor to specify the exact time for the medications in the prescription, but the facility did not receive the updated prescription. Based on the interviews conducted, the facility administered the medications according to doctors' prescriptions. The facility did not receive an updated prescription from the doctor, and the facility followed the facility policy to administer medications to residents. Lack of supervision resulting in resident wandering from the facility: On 8/19/2021, the Department interviewed R1's family member (FM). FM stated on 6/13/2021, at 9:00PM, he/she received a phone call from the facility that R1 eloped from the building but was found by staff in facility campus. On 8/20/2021, LPA interviewed ED. ED stated couple months ago, R1 walked out for fresh air without wearing pendant alarm. ED stated facility staff found R1 disappeared and reported to the facility immediately. ED stated facility staff all searched around and found R1 outside the building but still in the facility campus. Staff took R1 back to building immediately and notified FM. ED stated the facility implemented an action plan to prevent the situation to occur again and sent the action plan to FM. ED stated the facility tried to communicate with FM to discuss how the facility should improve to help residents, but the facility did not receive any response from FM. Continue on LIC9099-C. Page 3 of 4. Based on the interviews conducted, R1 eloped from the facility building without wearing Pendant alarm ring that was the reason why the pendant alarm did not sound. Staff found R1 had disappeared and immediately reported to the facility. The facility immediately had facility staff to search for R1 and found R1 outside the building but still in facility campus. The facility implemented an action plan to prevent similar incidents to occur again. Facility is charging for services not provided: On 8/19/2021, the Department interviewed R1's family member (FM). FM stated he/she enrolled R1 into an activity program and paid the monthly fee. FM stated most of the time the facility activities were not provided. FM stated the facility did not refund the fee. On 8/20/2021, LPA interviewed ED. ED stated the facility provided many activity programs to residents, but due to the COVID pandemic, there were many programs that had to change the content of the activities. ED stated the facility follows the CDC and local health department guidelines to change the activity. ED stated the purpose of the changes is to keep the residents and staff healthy and safety. ED stated the facility did not refund the fee for activity because the corporate was discussing how to handle it. On the same day, LPA interviewed Memory Program Coordinator (MPC) for the program activity during pandemic. MPC stated the facility activities made some changes due to COVID pandemic, but none of residents complained about the activity of the programs. MPC stated the activity staff, and the residents all wanted the activity to continue. Based on the interviews conducted, the facility provided the activities to residents, but due to the COVID pandemic, the facility activity programs were changed to follow CDC and local health department guidelines. The Department has investigated the above allegations. Based on documents reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED . An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. No citations cited under California Code of Regulations Title 22. Exit interview conducted with MPC. The report was provided to MPC for signature. A copy of the report was provided to MPC. Page 4 of 4.