complaint·July 11, 2024

Staff confine residents to their beds with use of other furniture. – SUBSTANTIATED It was reported that staff will push the recliners in the rooms to the side of the resident’s bed to block the residents from getting out of their beds. LPA reviewed Resident 2 (R2) LIC602 Physicians Report which states that R2 is non-ambulatory. Administrator stated that two staff told her that a family member of Resident 2 (R2) told them to move a recliner at the top of R2’s bed to act as a guard rail to keep R2 from falling out of bed. Administrator explained to the family member that the facility cannot do this, it is against regulations and the family member said they understood. This allegation is substantiated. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview conducted and a copy of the report was provided to administrator Audra Audino. Staff apply restraints to residents in wheelchairs limiting use of hands. - UNSUBSTANTIATED It was reported that hat staff are using some kind of restraining strap on residents’ arms who have wheelchairs. During as visit on 04/18/2022 LPA observed 10 residents in the dining area waiting for their lunch to be served. 4 of the residents were in wheelchairs, no restraints or postural supports were being used on residents. LPA observed staff assisting a resident in a wheelchair down the hallway, no restraints or postural supports. When exiting the facility LPA observed 8 residents and 1 visitor in the front garden area. 3 residents were in wheelchairs, no restraints or postural supports were observed. 5 of 5 staff stated that restraints are not placed on residents who use wheelchairs. Administrator stated that restraints nor postural supports are used on residents. Non-ambulatory residents developed pressure injuries while in care due to not being repositioned in bed. - UNSUBSTANTIATED It was reported that residents who are non-ambulatory are developing pressure injuries due to the staff not repositioning them on a regular basis. 4 of 5 staff stated there are no non-ambulatory who currently have pressure injuries. 4 of 5 staff stated that they re-position non-ambulatory residents once per hour. 1 of 5 staff stated that all of the residents can re-position themselves. Administrator stated that no non-ambulatory residents currently have pressure ulcers. Staff reposition non-ambulatory residents at least every 2 hours, but the facility does not have any residents who cannot re-position themselves. Continued on LIC9099-C Non-ambulatory residents are being skipped during meal distribution. - UNSUBSTANTIATED It was reported that residents who are non-ambulatory are being skipped during meal distribution. On 04/18/2024 LPA went to the room of Resident 1 (R1) and observed her in bed feeding herself her lunch. Resident appeared to be clean, comfortable and in good spirits. 4 of 5 staff stated if a non-ambulatory resident chose not to come to the dining room their meal is brought to them. Administrator stated that non-ambulatory residents do not miss meals. If the resident does not want to come to the dining room for their meal staff would serve them in their room. The facility does have one resident (R1) who always refuses to come out of their room and eats all of their meals in their room. Staff do not ensure non-ambulatory residents receive bathing assistance. - UNSUBSTANTIATED It was reported that residents who are non-ambulatory are not receiving bathing assistance. LPA reviewed ADL charting for 3 residents for the month of March 2024. All three resident received showers as scheduled except when the resident refused their shower which as noted in the chart. 5 of 5 staff stated that residents are showered three times a week but have the right to refuse showers. Administrator stated There is a shower schedule. Most residents are 2-3 times per week or if they are soiled, they get showers more frequently as needed. R1 refuses frequently but we try to get R1 in at least once per week. Continued on LIC9099-C Staff are providing wound care to residents without supervision of a skilled professional. - UNSUBSTANTIATED It was reported that some of the care staff are providing wound care to some of the residents. No specific details were provided by complainant. Staff interviews revealed that staff provide first aid assistance for cuts and scrapes, if a resident has a more serious wound home health provides the wound care. Administrator stated We are all trained in first aid so all staff can apply a Band-Aid. We have one resident, R3, who takes blood thinners and has super thin skin so when R3 gets a skin tear home health come out and does the care for that. Staff do not ensure residents are spoken to in an appropriate manner. - UNSUBSTANTIATED It was reported that that staff are verbally abusive to residents. No specific details were provided by complainant. Staff stated they had not heard any staff speaking roughly to residents but occasionally staff do have to speak loudly to certain residents. Administrator had not witnessed or heard that any staff had spoken roughly to residents. Staff handle residents roughly. - UNSUBSTANTIATED It was reported that that staff are physically abusive to residents and handle the residents roughly. No specific details were provided by complainant. Staff had not witnessed any staff handling residents roughly. Administrator stated About a week ago one staff told me that my new employee was being a little bit rough, like when she is taking clothes off so I had a talk with her and she said she didn’t realize she was being rough and would pay more attention. Continued on LIC9099-C Staff do not ensure residents medications are dispensed as prescribed. It was reported that residents’ medications are not always dispensed correctly to the residents or they are missed. No specific details were provided by complainant. 3 of 4 staff stated they were not aware of any recent medication errors. Administrator stated they had not had any medication errors lately nor had any dosages been skipped. Staff does not ensure reporting requirements are followed. - UNSUBSTANTIATED It was reported that staff don't submit incident reports to licensing when events with residents occur. All staff stated they have been trained on reporting requirements and follow the facility’s reporting procedures. Administrator stated Whenever there us an incident staff call the on call, and the on call has them write an incident report and I fax them over to licensing. They have been reporting. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are UNSUBSTANTIATED. An exit interview was conducted. A copy of the report was provided to administrator Audra Audino.