Inspector’s narrative
What the inspector wrote
On March 15, 2023, LPA David Marrufo interviewed R1’s Power of attorney, (POA). POA stated the following, “they called me as soon as R1 had a fall and called me and made a record of it. They checked R1 the next morning and there was no problem.” POA stated the facility staff informed him/her that R1 had a bad step and lost his/her balance.
On March 15, 2023, LPA Marrufo interviewed administrator (ADM) and Licensee (LN). ADM & LN stated R1 had a fall on February 22, 2023 & notified the POA regarding the fall and recorded it in internal records. ADM & LN stated it he/she wouldn’t describe it as a fall, but more of a trip and R1 only hit their knee. ADM stated the resident was assessed and no bruises or injury was observed. ADM stated R1 was assessed the following day as well, and no injury was observed.
On November 16, 2023, LPA's Monter and Partoza interviewed ADM regarding the fall. ADM re-enacted R1 stumbled and fell on his/her knee. ADM stated R1 lost balance due to losing her footing in the living room. ADM stated R1 then slowly fell on his/her knee and then laid on his/her side. ADM stated R1 then used the recliner next to him/her to lift themselves up.
The Department has completed the investigation of the above allegations. Based on interviews conducted and record review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.
Facility is not providing activities for the residents.
On March 8, 2023, the Department received a complaint alleging the facility is not providing activities for the residents.
On March 15, 2023, LPA Maruffo & Monter toured the facility. LPAs observed resident R1 participating in a puzzle activity in the morning and was later escorted with a staff member for a walk outside.
A review of Willow Oaks Senior Living’s Policy & Protocol for activities states the following: the ADM is responsible for planning the daily schedule for activities and residents are encouraged to contribute to the planning, preparation, and critique of planned activities. A monthly calendar of activities was observed during the visit.
Page 2 out of 3
On March 15, 2023, LPA interviewed residents R1-R3. R1 stated the facility provides him/her with things to do. R2 stated he/she did not want to be interviewed. R3 is nonverbal and could not answer LPA’s questions.
On March 15, 2023, LPA interviewed R1’s Power of attorney, (POA). POA stated “they do provide activities for R1. The activities that they have is that they get together at the table and do scrabble. When the weather is nice, they walk R1. They do have activities. I have seen them walk R1.”
On March 15, 2023, LPA interviewed ADM, S1 and Licensee. ADM stated the facility does provide activities such as walking, television, scrabble, listening to music, and arranging flowers. S1 stated the facility provides activities for the residents. S1 stated they assist residents with walking by holding their hands. The licensee stated the facility provides multiple activities such as; watching television, bingo, cards, walking.
On November 16, 2023, LPA's Monter & Partoza interviewed R2, R4, R6-R8. R7 and R7 stated the facility does provide activities such as walking dominos, and bingo. R6 and R7 stated the facility does offer but they choose to to other things. R2 stated the home does have activities but he/she prefers to stay and watch television. R3 and R8 was unable to answer LPA questions due to inability to speak.
The Department has completed the investigation of the above allegations. Based on interviews conducted and record review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.
Page 3 out of 3
On March 15, 2023, LPA David Marrufo interviewed R1’s Power of attorney, (POA). POA stated the following: “They generally lock the bathroom door. They check R1 about every hour or so.” POA added, “I know that on several times, R1 has been in there by himself/herself and took his/her pants off and put his/her feces all over the walls and that happened several times. That is the reason that they shut the door. R1 tries to get rid of his/her feces.” POA stated he/she gave verbal permission to lock the bathroom door.
On March 15, 2023, LPA interviewed ADM, S1, & Licensee. ADM and S1 stated R1’s bathroom was locked due to R1 “digging out feces and putting on the walls." ADM also stated that they found R1's clothes in shower and staff feared fall risk at night. ADM stated R1 would hide used toilet paper around his/her bedroom. ADM stated they have found R1's diaper hidden under his/her roommate’s bed. The licensee stated R1's bathroom is locked, due to feces smearing that occurred in the first week. ADM and Licensee stated they had a verbal agreement with R1's family member regarding locking the bathroom door during the admission of R1.
On November 13, 2023 LPA interviewed R1’s POA. POA stated the facility locked R1’s bathroom door due to smearing behavior and to keep R1 out of that bathroom for his/her safety, and to keep him/her going to one bathroom.
On November 16, 2023, LPA's Monter and Partoza interviewed ADM and Licensee. ADM stated R1's behavior was an ongoing issue in the first occurred frequently. ADM stated the facility does not have a toileting log for R1. ADM stated the facility does not have a wake night staff. ADM stated that sometime when we are busy, that's when she's doing it, the smearing. ADM stated that the behaviors incidents regarding would eventually become once a week. ADM stated before R1 left the facility, R1 continued to have behaviors regarding hiding his/her feces and diaper. ADM stated the bathroom door was locked when R1 was unsupervised. ADM stated " we didn't want her to go to the bathroom alone." ADM stated " it didn't happen in the other bathroom because she was supervised." Licensee stated R1 did not smear in the other bathroom because some one was with him/her. Licensee and ADM stated R5 was agreeable to having the private bathroom door locked. Licensee stated the reason the facility locked the door was because R1 was washing their diapers in the toilet. Licensee stated he/she feared risks around water in the toilet bowel without supervision. Licensee stated the other bathrooms are available to R1.
Page 2 out of 3.
A review of the facility floor plan shows that R1’s bedroom is bedroom #1, which has a private bathroom. Bedroom #1 is a shared bedroom, for R1 and R5.
In addition, ADM also noted on LIC625 that R1 requires a toilet scheduling every 2-3 hours and R1 needs to be supervised when he/she enters the bathroom on his/her own at all times.
Based on interview with ADM, there is no awake night staff and there is no toileting log. ADM and licensee stated R1’s shared bathroom was locked as a solution to prevent resident from smearing feces which also violates R1 and R5’s personal rights under code section
87468.1(a)(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
R1 shared a bedroom with R5. Staff stated that R5 gave permission to lock bathroom. R1 has neurocognitive disorder.
ADM stated, “…sometimes when we are busy, that's when he/she’s doing it, the smearing.” ADM stated that R1 behaviors occurs during sleeping hours. Staff stated that they would at times hear movements from R1’s bedroom, and also during waking hours at 6:30AM wherein R1 was found with feces in bed, clothing and bedroom walls. ADM stated the smearing behavior always happened when he/she was alone. ADM also stated R1 would hide used toilet paper around his/her shared bedroom. ADM stated they have found R1's diaper hidden under R1's roommates bed.
The Department has investigated the above allegation. Based on records reviewed, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED.
Deficiencies are being cited. See LIC 9099-D. Exit interview conducted with Licensee Irish Ladwig and a signed copy of this report was provided along with appeal rights. Page 3 out of 3.
On 11/20/2023, at approximately 4:45pm. The report was presented to the Licensee and Licensee refused to sign. A copy of the report was printed and was handed to ADM. Appeal rights were printed and handed to ADM.
