complaint·March 4, 2025

During the investigation process, on 09/24/24 LPA Sarangi interviewed staff persons and they reported that they had the video training that met the licensing training requirements. During the month of October 2024, the staff were interviewed by LPA Gurriere and nearly all felt that they did not have sufficient training while working on the floor as a “care provider or as a medication technician.” Staff reported that they had one to three days of training on the floor shadowing another care provider before they were to provide care and supervision to the dementia residents in memory care on their own. Staff reported that they did not agree that their time training on the floor was adequate. Substantiated . Staff do not respond to resident’s call for assistance in a timely manner . During the interview process, the administrator and seven staff persons working in the memory care unit were interviewed. In addition, records were obtained. Residents were not interviewed due to their dementia status. During the investigative process, most staff reported that the memory care unit is understaffed and cannot provide aid in a timely manner. It was stated that the staffing for the memory care unit was one care provider and one med technician per shift, (three separate shifts) to provide care and supervision for dementia residents. During LPA Gurriere’s visit on 10/08/24 it was confirmed that there was one care provider and one med technician for 13 dementia residents. It was stated that if the care provider is changing a resident in the resident’s room and the med technician is in the med room preparing medications, there is no one else in the common area to provide care and supervision to the residents. Substantiated. Staff do not ensure resident’s toileting needs are met . During the interview process, the administrator and seven staff persons working in the memory care unit were interviewed. Residents were not interviewed based on their dementia status. In addition, records were obtained to include the resident’s (Resident 1) Physician Report, Admission Agreement, Communication document, Medication Administration Records (MARs), Hospice Notes, Initial Plan of Care, Pull Switch Log, Service Plan, Preventions/Safety Measures for Falls, Incident Reports of Fall Injuries, and Staff Names and Cell Phone Numbers. During the investigation process, it was reported that the resident (Resident 1) was found by the resident’s family member and two staff persons that started their shift, laying in urine and feces. In addition, the resident’s bedsheets were soaked and soiled. It was reported that the resident was in this state and that it was believed that the nighttime shift did not check or change the resident in a timely manner. It was reported that staff try to check on the resident’s toileting needs every two hours; however, when asked for the toileting/incontinence log, it was reported by the administrator that there was none. Substantiated . Staff do not keep facility clean and sanitary . During the interview process, the administrator and seven staff persons working in the memory care unit were interviewed. Residents were not interviewed based on their dementia status. During the investigation process, it was reported that the memory care unit did not have a housekeeper to provide cleaning for approximately one month, due to the housekeeper leaving. It was reported that during that time, there was a lack of cleaning in resident rooms. It was stated that the staffing for the memory care unit was one care provider and one med technician per shift, (three separate shifts) to provide care and supervision for dementia residents. It was stated that a housekeeper may clean intermittently, and that staff are to clean in between when the housekeeper does not clean. Staff reported that for each shift, the care provider and the med tech were to provide housekeeping, laundry, food serving, incontinent care, showering, care and supervision, and passing of medications. Substantiated . Facility call system is in disrepair . During the interview process, the administrator and seven staff persons working in the memory care unit were interviewed. Residents were not interviewed based on their dementia status. In addition, records were obtained to include the resident’s (Resident 1) Physician Report, Admission Agreement, Communication document, Medication Administration Records (MARs), Hospice Notes, Initial Plan of Care, Pull Switch Log, Service Plan, Preventions/Safety Measures for Falls, Incident Reports of Fall Injuries, and Staff Names and Cell Phone Numbers. During the investigation process, it was reported that at times the call system and the necklace call button did not work. It was reported that recently, a call system on the wall fell off the wall, a call for one room rang in a different room rather than the original room and that there is not always a good reception service to ensure that staff are being notified of a call. Substantiated . Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard have been met, therefore all of the above allegations are found to be Substantiated . California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Appeal Rights were explained and provided to the facility representative listed above and an exit interview was conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed. During the investigation process, it was reported that staff were present when the resident (Resident 1) fell in the common area while trying to ambulate around a chair. The resident tried to walk around a chair; however, her foot caught one of the chair’s legs and the resident fell onto her right hip. Three staff persons witnessed the fall and there was nothing that they could have done to prevent the resident from falling. The resident was sent to the hospital shortly after the fall; she suffered a hip fracture. Unsubstantiated . Staff mismanaged resident medication . During the interview process, the administrator and seven staff persons working in the memory care unit were interviewed. Residents were not interviewed based on their dementia status. In addition, records were obtained to include the resident’s (Resident 1) Physician Report, Admission Agreement, Communication document, Medication Administration Records (MARs), Hospice Notes, Initial Plan of Care, Pull Switch Log, Service Plan, Fall Preventions/Safety Measures for Falls, Incident Reports of Fall Injuries, and Staff Names and Cell Phone Numbers. During the investigation process, it was reported that the resident (Resident 1) had moved, and the resident did not have medications available to review. The resident’s MARs were reviewed and were in order, as required. Although the above allegations mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the above findings are Unsubstantiated .