complaint·December 21, 2024

LPA Valerio reviewed progress notes for R1. R1 was admitted to the facility on 11/24/23. During admission, the staff on shift notes that R1's Colostomy bag was leaking. The staff  emptied and replaced the bag. According to the staff, the staff educated family and caregiver on emptying colostomy bag and advised to call nurse for assistance when needed.  Based on R1's records, R1 had home health services, which included visiting nurses for nephrostomy care.  R1 was sent to the hospital by the facility on 11/25/23 at 5:30 AM due to R1's family member observing the bag to explode and the family member did not have supplies to change it. R1 did not return to the facility and was only at the facility for less than 24 hours. According to an interview with Staff 1 (S1) the facility call logs are not available past 6 months. Anything before that the third party contractor may or may not be able to retrieve the information. According to the RP, Resident 2 (R2) had been reporting rats being seen and although facility maintenance staff put a rat trap in the room, R2 attempted to catch the mouse, which resulted in a fall. According to the RP, the facility failed to respond to R2 call for help. LPA Valerio reviewed facility records for R2. R2 was observed to have a fall on 11/14/2023. R2 was found by staff after they heard a loud thump. R2 stated, "I was trying to catch the mouse in my apartment, lost my balance, and fell back dropping the cat food. While falling down I hit my head on the floor and landed on my right wrist." Facility staff immediately contacted 911, checked resident vitals, and was sent to the hospital shortly after. Based on records review, the residents current assessment now have a fall risk in place. The latest assessment was conducted on 10/04/2024. According to an interview with Resident 3 (R3), R3 feels that staff have always been attentive to their needs. R3 cannot recall how last year (2023) was entirely but nothing came to mind. R3 reports that there are many staff that are working all the time. According to an interview with Resident 4 (R4), R4 likes living at the facility and has been at the facility for thirteen years. R4 reported staff assist resident when R4 needs assistance with toileting. Anytime R4 calls for help, staff are there to assist R4. Continues on LIC 9099 -C... On 01/04/2024, this report was amended to remove irrelevant information and confidential pronouns. LPA Valerio reviewed the December Staff Schedule for 2023. LPA observed the facility scheduled a minimum of two Medication Technician (MT)s and three Caregivers (CG) for AM shift (6:00 AM - 2:00 PM) and PM Shift (2:00 PM - 10:00 PM). During overnight shift, there was one MT and two CG scheduled. LPA observed that on 12/04/23 and 12/05/23, there was a call out and therefore only two caregivers were on shift for the PM shift. On 12/09/23, the facility had two caregivers call out that day and therefore, there was only one CG on shift along with two MTs. On 12/13/2023, LPA observed one CG staff call out leaving only two MTs and two CGs on shift for the AM shift. For the week of 12/17 - 12/23, the facility had scheduled a minimum of two MT and three CG on all shifts. On 12/24/2023 and 12/23/2023, they had scheduled an extra LVN and caregiver for this shift, which left the facility with three MTs and four CGs during PM shift. For 12/23/23 - 12/31/23, LPA Valerio two MT and three CG on each shift for AM. For PM shift, they scheduled three MT and three CG. Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore the allegations are unsubstantiated. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. An exit interview was held, and a copy of report was left at the facility.