Complaint·August 14, 2024

Facility staff are not meeting the needs of the resident It was alleged that the facility staff are not meeting the needs of the residents due to resident (R1)’s private caregiver providing all activities of daily living (ADL) care to include showers, dressing, transportation to medical appointments, and medication administration. Based on review of R1’s needs and services plan, it’s indicated the facility will provide assistance as needed e.g. positioning, ambulation, toileting, feeding, dressing, bathing, way-finding, encourage daily physical activities such as walking, schedule daily walks, give medications as needed, and perform regular intentional rounding to assess need for position change, pain assessment, and personal needs such as toileting. Based on review of R1’s signed admission agreement, R1 was paying a monthly fee for “total care: personal full assistance with ADLs…” and “basic services”. The facility’s basic services includes, “assistance with bathing, dressing, grooming, toileting, eating, continence, transferring from bed or chair, and other personal needs”. Throughout the course of this investigation, 6 residents, 4 staff, and 1 witness was interviewed. Based on interview with R1’s private caregiver (W1), it was stated that W1 assists R1 with dressing, bathing, hygiene, grooming, daily activities like walks, and appointments. W1 states the facility’s caregivers dispenses R1’s medication and W1 gives the medication in a cup to R1. W1 states the facility’s caregivers does the laundry and cleans R1’s room. Based on staff interview, 4 out of 4 staff confirmed that R1 has a private caregiver during the day that assist R1 with his/her activities of daily living (ADL) care to include dressing, bathing, toileting, and activities. 4 out of 4 staff state that the facility’s staff only assists the resident during the night. During the day, the facility’s staff assists only with dispensing medications, meals, laundry, and cleaning. PAGE 2 OF 6. Based on interview with the Administrator on 07/19/2023, it was states that the facility staff manages the medications, prepares the food, does laundry, and clean R1’s room. ADM stated that R1’s 1:1 caregiver does “everything” and the facility staff helps out when R1’s 1:1 private caregiver goes on break. On 02/09/2024, the Administrator (ADM) was re-interviewed. Based on interview, it was stated that due to the time it took to assist R1 with activities such a walking, walking to a coffee shop, and to medical appointments they started the topic of a private caregiver for R1’s safety. The private caregiver was like a companionship. ADM stated that the facility’s staff are responsible for ADL care to include showers, grooming, and toileting. It was stated that at that time, there was confusion on the facility staff and private caregivers’ responsibilities. Private care givers administer medications to resident It was alleged that R1’s private caregivers will get the cup of medication and administer R1’s medications. Throughout the course of this investigation 4 staff, and 1 witness was interviewed. Based on interview with R1’s private caregiver (W1), it was stated the facility’s caregivers dispenses R1’s medication and W1 gives the medication in a cup to R1. Based on staff interview, 4 out of 4 staff state R1’s private caregiver administers R1’s medications. S1 states R1’s private caregiver asks for permission to get R1’s medication cup and will give it to R1. S4 stated when dispensing R1’s medication they dispense the medication in the cup then hand it over to the personal caregiver. Staff then checks on R1 to make sure R1 take his/her medication. Based on interview with the Administrator and Licensee, it was stated that the private caregiver did administer the medication to R1 and that it did happen. Licensee states R1's private caregiver is trained on medication administration. PAGE 3 OF 6. Facility is in disrepair It was alleged that the facility is in disrepair as there was only one shower available for the residents and staff to use in the home. It was also alleged that the bathroom near R1’s bedroom had a hole on the left side of the toilet, and the bathroom fan was dysfunctional. On 07/19/2023, LPA Dolores toured the facility and observed the bathroom shower located in the hallway contained a large chair and boxes. Based on staff interview, it was stated that the shower was not in use because it is in disrepair. It was stated that all residents and staff used the shower near R1’s bedroom. On 01/24/2024, LPA Monter toured the facility and observed the bathroom shower located in the hallway was fixed. Based on review of the photographs obtained, it shows the bathroom near R1’s bedroom contained a hole behind the left side of the toilet. The photo also shows the lid of the fan was placed on top of the toilet. It was stated that the fan was replaced by the Licensee. Based on interview, R1’s responsible party voluntarily hired a contractor to fix the hole behind the toilet. Facility water temperature is too hot It was alleged that the facility’s water temperature is too hot. On 07/19/2023, LPA Dolores measured the hot water temperature near R1’s bedroom. The hot water temperature was measured at 125 degrees Fahrenheit. On 07/19/2023, the Administrator was interviewed. Based on interview, it was stated that they had an issue with the water heater and shower. It was stated that they hired a plumber who came to the facility 2 weeks ago. It was stated that sometimes the staff doesn’t tell the Administrator right away, when things are broken. On 01/24/2024, LPA Monter measured the hot water temperature near R1’s bedroom. The water temperature rose to 125 degrees Fahrenheit then dropped to 100 degrees Fahrenheit. Staff stated it might be due to the washing machines currently running. On 02/09/2024, LPA Dolores measured the hot water temperature to be maintained at 130 degrees Fahrenheit. PAGE 4 OF 6. Facility is not following resident's admission agreement It was alleged that the facility is not following R1’s admission agreement as the facility did not provide R1 with basic services to include hygiene items, weekly laundry, cleaning of R1’s room, assistance for transportation to appointments, and activity of daily living (ADL) care. It was alleged that R1’s private caregiver assisting R1 with bathing assistance, dressing assistance, tray for meals, changing, brushing of teeth, providing R1’s responsible party with updates, and medication administration. Based on review of R1’s signed admission agreement, it’s stated that the licensee will provide the resident with basic services to include (but not limited to): hygiene items or general use of such soap and toilet paper; plan/arrange/and/or provide for basic transportation to medical and dental appointment; assistance with bathing, grooming, toileting, eating, continence, transferring from bed or chair, and other personal needs; assistance in meeting necessary medical and dental needs; assistance with taking prescribed and over-the-counter medications. Throughout the course of this investigation, 6 residents, 4 staff, and 1 witness was interviewed. Based on interview with R1’s private caregiver (W1), it was stated that W1 assists R1 with dressing, bathing, hygiene, grooming, daily activities like walks, and appointments. W1 states the facility’s caregivers dispenses R1’s medication and W1 gives the medication in a cup to R1. W1 states the facility’s caregivers does the laundry and cleans R1’s room. Based on staff interview, 4 out of 4 staff confirmed that R1 has a private caregiver during the day that assist R1 with his/her activities of daily living (ADL) care to include dressing, bathing, toileting, and activities. 4 out of 4 staff state that the facility’s staff only assists the resident during the night. During the day, the facility’s staff assists only with dispensing medications, meals, laundry, and cleaning. PAGE 5 OF 6. Based on interview with the Administrator on 07/19/2023, it was states that the facility staff manages the medications, prepares the food, does laundry, and clean R1’s room. ADM stated that R1’s 1:1 caregiver does “everything” and the facility staff helps out when R1’s 1:1 private caregiver goes on break. On 02/09/2024, the Administrator was re-interviewed. Based on interview, R1’s private caregiver’s role was to provide companionship as R1 was a high fall risk due to his/her medical condition. It was stated that there was initially confusion with staff and the private caregiver of their roles and responsibilities. The Administrator states the facility provides basic hygiene items, however, the resident's and/or resident's responsible parties may provide their own if there are specific brands they prefer. It was stated that R1's responsible party wanted to take R1 to medical appointments and sometimes the private caregiver would take R1 to R1's medical appointment and meet with R1's responsible party. During the initial investigation on 07/19/2023, there was no written agreement or contract that was produced to differentiate the responsibilities of the facility staff and private caregiver. Based on record review, on 08/23/2023 a “sitter & companion role and responsibilities” contract was written showing the breakdown of duties for caregivers and the private care giver. The Department has investigated the above allegations. Based on interview, record review and observation the preponderance of evidence standard has been met, therefore, the above allegations are SUBSTANTIATED. Deficiencies were cited per California Code of Regulations, Title 22. LIC9099-D. This report was reviewed with Licensee, Irish Ladwig and a copy of the report and appeal rights were provided. PAGE 6 OF 6. Facility staff inappropriately touched resident It was alleged that a male staff had inappropriately touched R1. It was alleged that an alarm went off in R1’s room and the staff (S2) saw R1 was almost falling out be bed. S2 caught R1 and R1 perceived it to be inappropriate touching. It was alleged that S2 touched R1 around the abdomen area. Throughout the course of this investigation, 6 residents, 4 staff, and 1 witness was interviewed. Based on staff interview, S2 denied any incidents of inappropriately touching of residents. S2 stated there was an incident that happened at the dining table where R1 looked like he/she was about to fall. S2 ran and grabbed R1 under his/her arm because R1 almost fell down. S2 did not remember where he/she touched R1. S2 states it happened once and it was only to help R1 because he/she was about to fall. 3 out of 3 staff denied the observation of staff touching residents and R1 inappropriately. Based on resident interview, 5 out of 6 resident’s denied staff inappropriately touching them. 5 out of 6 residents’ denied the observation of staff inappropriately touching another residents. 1 out of 6 resident’s was unable to be interviewed. Based on interview with R1's private caregiver (W1), W1 only heard of the incident. It was stated that R1 did not have a private caregiver at the time. Facility is not securely storing medication It was alleged that R1’s private caregiver kept one of R1's medication in R1’s room. Based on interview with R1’s private caregiver (W1), it was stated the facility’s caregivers dispenses R1’s medication and W1 gives the medication in a cup to R1. W1 states the medication is locked in the kitchen, which W1 does not have access to the medication cabinet. PAGE 2 OF 4. On 07/19/2023, LPA Dolores entered into R1’s room and did not observe medication that was left out in R1's room. LPA Dolores toured the facility and entered in all resident bedrooms and did not observe any medication that was accessible to the residents. LPA observed the medication storage area was secured in a locked cabinet and inaccessible to residents in care. On 01/24/2024, LPA Monter observed the medication storage area was secure and inaccessible to residents in care. Facility is not following facility meal plan It was alleged that the facility is not following the meal plan because there was a time where there were no fresh fruits or vegetables delivered and the resident’s were eating canned food and microwave foods. It was also alleged that the resident’s were not being served green salads. Throughout the course of this investigation, 6 residents and 3 staff were interviewed. Based on resident interview, 5 out of 6 residents states they get vegetables and fruits every day. 1 out of 6 residents was unable to be interviewed. R2 states they eat a lot of frozen food like vegetables and meat. It was stated they have Salisbury steak with fresh mashed potatoes and vegetables. It was stated that the facility serves them salad. It was stated that they have fruit every day. R3 states they get fresh vegetables practically every day to include a salad. R3 states he/she doesn’t always eat the salad. R4 states the vegetables are mushy and frozen. R4 states they get frozen vegetables 5 days a week. R4 states that sometimes they get fresh beats and carrots. R4 preferred certain fruits than what the facility was serving. R5 states the food is very good. R4 states they serve both frozen and fresh fruits and vegetables. R6 states the facility serves ordinary things to include fruits and vegetables. PAGE 3 OF 4. Based on staff interview, S1 states to ask the resident’s what they want to eat. It was stated that they serve salad every afternoon. S1 states they do not serve frozen vegetables and it’s always fresh. S2 states they ask the residents what they want to eat because each resident likes different dishes. S2 states they use both frozen and fresh vegetables but usually use fresh vegetables. The Administrator states that groceries are delivered every 2 weeks and as needed. It was stated that the resident’s are very specific with what they want to eat and ADM accommodates to their needs if able. ADM states the menu posted on the refrigerator is only a sample. On 07/19/2023, LPA Dolores observed the kitchen had at least 2 days worth of perishables and 7 days worth of non-perishable foods. LPA Dolores observed fruits to include apples and watermelon and vegetables to include lettuce, tomatoes, onions, and potatoes. The Department has investigated the above allegations. Based on interview, record review and observation the above allegations are unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid there is not a preponderance of evidence to prove the allegations did/did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Licensee Irish Ladwig and a copy of the report was provided. PAGE 4 OF 4.