complaint·December 6, 2024

The review of R1’s service plan states that R1 has full dentures but refuses to wear the dentures. 4 staff members were interviewed. Based on staff interview, 4 out of 4 staff did not remember R1 using dentures. It was stated that R1 moved from Assisted Living to Memory Care and staff did not remember R1 moved into memory care with dentures. Based on record review of R1’s safeguard of personal property and valuable form, there were no items to include the dentures that was entrusted to the facility. The word “waived” is written across the form and the form was signed and dated by R1’s responsible party on 03/17/2021. It was alleged that the facility staff did not ensure that R1’s hygiene needs were met while in care as it was observed that R1 was filthy after not being bathed for a week. It was alleged that R1’s hygiene needs were not met because the facility was short staffed. The date of this encounter is unknown. Based on record review, R1’s showers were scheduled twice a week and required staff hands on assistance. 4 staff members were interviewed. Based on staff interview, 4 out of 4 staff denied R1’s hygiene needs being neglected by the staff. Staff states that R1’s family did not bring up any concerns that R1 wasn’t showered for a week. Staff states the facility was short staffed around July 2023 but denied the shortage of staff reflecting on the shower schedule. Staff states the residents were still being provided their showers on their scheduled days. The review of the facility’s staffing schedule shows that there were at least 3 staff scheduled in memory care, in the AM and PM. It was alleged that staff did not ensure R1 had clean linens while in care as there was a day where R1’s responsible party and R1’s social worker needed to change R1’s bedsheets because they were soiled. Page 2 of 3. The date of this encounter is unknown. 4 staff members were interviewed. Based on staff interview, 4 out of 4 staff were not able to recall a time where R1 had soiled linens. It was stated that if staff were to observe that a resident’s sheets are soiled, the staff would immediately change the sheets and put new ones. It was alleged that staff did not follow safe sanitation practices as a staff who wore disposable gloves for cleaning was touching other surfaces and items with the same glove on. It was stated that when R1’s responsible party placed R1’s soiled items outside R1’s bedroom door for laundry service, the staff picked up the soiled linens with possibly the same disposable gloves. It was stated that the staff did not serve R1 any food. The reporting party did not indicate that the staff provided any care to the resident or other residents with the same gloves used during cleaning. 4 staff members were interviewed. Based on staff interview, it was stated that they spoke with the alleged staff who did not follow safe sanitation practices, and the staff denied the allegation. It was stated that facility staff are provided training on infection control. Staff state that they can use gloves when cleaning but they are trained to change out their gloves before they provide any care to the residents. It was stated that staff are trained to change their gloves after every resident when assisting them with ADL (activities of daily living) care. Based on record review, infection control training was completed on 05/25/2023. 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 is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Health Services Director, Jocelyne Bailon and a copy of the report was provided. Page 3 of 3.