Inspector’s narrative
What the inspector wrote
Facility did not meet resident’s hygiene needs
In June 2021, resident (R1) was brought to a nail salon where it was found R1 had multiple hard dark matter and yellow gunk underneath the fingernails.
Based on observation of the photograph provided from R1’s visit to the nail salon in June 2021, the photograph showed the yellow and black gunk/hard matter that was removed from underneath R1’s fingernails.
Based on record review, R1’s services plan dated April 19, 2021 states the service of bathing/showering seven times per week and grooming two times a day. R1’s physician report states the need of assistance in bathing and toileting.
The facility did not ensure to meet R1’s hygiene needs despite the service of daily bathing/showering from the observation of the build-up of yellow and black gunk underneath R1’s fingernails.
Facility did not communicate properly with family member
In January 2021, the facility had a COVID-19 outbreak resulting in multiple residents and staff contracting COVID-19. R1 was part of the group of residents who contracted COVID-19 and recovered.
During a care conference in August 2021, R1’s responsible person(s) was informed R1 had not received the COVID-19 vaccination after recovery from COVID-19 in January 2021. Based on record review, R1’s records did not state the responsible person(s) was notified or received a follow-up that R1 had not yet received the COVID-19 vaccine after recovery.
Resident’s room not large enough to allow for easy passage and comfortable usage of bed and other furniture
In January 2021, R1 was relocated to a shared room in memory care. R1 used a wheelchair and hospital bed.
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Facility not following COVID 19 guidance or protocol
In January 2021, the facility had a COVID-19 outbreak resulting in multiple residents and staff contracting COVID-19. Resident (R1) was part of the group of residents who contracted COVID-19.
On 03/16/2022, LPA Donovan interviewed 3 out of 3 staff members (S1 – S3). Based on interviews, the facility follows COVID-19 guidance and protocols by implementing daily COVID-19 symptom screening for staff and residents, deep cleaning, disinfecting, encouraging social distancing, and encouraging residents to wear a mask during an outbreak.
Based on record review, R1’s responsible party signed and acknowledged the facility’s COVID-19 Disclosure for potential exposure, which was part of the admission agreement. The COVID-19 Disclosure for potential exposure states the possibility of residents or staff residing or working at the facility who may be infected with COVID-19 and despite precautions the risk of exposure to COVID-19 cannot be completely eliminated due to the methods and rate of transmission of the virus.
The facility reported the COVID-19 outbreak to the Department and was in contact with the Department during the outbreak. The Department did not note any issues or concerns during the outbreak.
In March 2021, R1 sustained an unwitnessed fall. R1’s responsible party was notified, but due to the pandemic, R1 was not sent to the hospital. Based on record review, R1 was able to get back up with assistance and had no complaints or discomfort. R1 was assessed by staff and monitored for 72 hours. There was no observation of apparent pain, discomfort, injuries, and bruises.
Resident’s room was not in good repair
It was alleged that R1’s bedroom was not in good repair by containing a small oval hole on the exterior side of the bathroom door, chipped paint on the walls, and the bathroom molding to be in disrepair.
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On 03/16/2022, LPA Donovan inspected the bedroom under investigation. The bedroom was vacant during visit. No immediate issues or concerns were noted.
On 09/14/2022, LPA Dolores observed the bedroom under investigation to be vacant. LPA observed the hole on the exterior side of the bathroom door in the bedroom had not yet been repaired. The hole did not penetrate to the interior side of the door and LPA did not observe the hole to be see through. The paint inside the bedroom was not observed chipped and bathroom molding was observed to be in good repair. LPA observed the bathroom was clean and sanitary.
Facility did not follow resident’s Admission Agreement
R1 was admitted to the facility in October 2020. In January 2021, R1 was relocated from Assisted Living to Memory Care. Based on record review, R1’s responsible party signed and dated the relocation form from assisted living to memory care.
In April 2021, R1 had an increase in services for continence and bathing/showering. One of the two services were requested by R1’s responsible person(s) to increase a service from one to seven days a week. One of the two services were increased based upon a routine assessment. Due to the increase in services, there was an increase of cost per month.
Based on record review, facility staff attempted to contact R1’s responsible person(s) multiple times to review and sign R1’s updated routine assessment. After multiple attempts, facility staff was able to review R1’s updated assessment with the responsible person(s). A few weeks later, R1’s responsible person(s) signed the updated assessment reflecting the requested additional increase in service.
R1’s signed residency agreement states a change in the level of care will be effective immediately and the responsible person(s) will be notified of the change within 2 business days. If a resident has a change in level of care, the facility will send the responsible person(s) the new assessment by email or inform the responsible person(s) verbally.
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Staff did not know how to operate hospital bed
In March 2021, resident (R1) sustained an unwitnessed fall. Based on record review, R1 did not sustain any injuries or bruises and did not complain of pain and discomfort. R1 was not transported for medical treatment due to the pandemic. Its alleged staff did not know how to operate a hospital bed which may have resulted in the fall.
On 09/14/2022, LPA Dolores observed a staff member demonstrate how to operate 2 hospital beds. Staff member was able to demonstrate how to operate the hospital bed to include positioning the bed and adjusting the side rails. Staff member states to be the person to train new hires on how to operate the hospital bed. Staff has procedures for when there are technical difficulties in operating the hospital bed.
The Department has investigated the above allegations. Based on interviews, observation, and record review the Department has determined 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 the alleged violations did or did not occur.
No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director, Flavio Silva and a copy of the report was provided.
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On 03/16/2022, LPA Donovan inspected 5 bedrooms in memory care. According to the staff interview, the room under investigation was a shared room with proper furniture to include two single beds, two dressers, and a folding chair.
On 09/14/2022, LPA Dolores inspected 8 bedrooms in memory care. It was observed the bedroom under investigation has a different layout compared to the other bedrooms, due to the bedroom being located in the corner of the facility.
On 12/14/2022, LPA, ED, and the Memory Care Director (MCD) measured a hospital bed, wheelchair, and the section of the bedroom where R1’s hospital bed was placed. LPA not observed enough space to maneuver a wheelchair to the bedroom's exit. LPA, ED, and MCD observed the length of a hospital bed being too long which did not allow for easy passageway to the exit with a wheelchair.
The Department has conducted an investigation of the above allegations. Based on interviews, record reviews, and observation, the preponderance of evidence standard has been met. Therefore, the Department found the above allegations to be SUBSTANTIATED
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Deficiencies are being cited per California Code of Regulations, Title 22. A plan of correction was developed with the Executive Director. This report was reviewed with Executive Director, Flavio Silva and a copy of the report and appeal rights were provided.
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