complaint·April 29, 2024

The resident was admitted in September of 2023 but did not have hygiene added to the needs and service plan until January of 2024. Documentation indicates that R1's wounds were miscategorized as pressure wounds but were actually due to urinary incontinence. R1's physician report makes no indication of cognitive impairment for R1. During the course of an interview with R1, R1 denies any neglect by staff. Based on the records reviewed and interviews conducted the allegation of "Resident developed pressure wounds while in care due to neglect" is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation my have happened, the preponderence of evidence does not prove it. An exit interview was conducted and a copy of this report and appeal rights were provided. T he skin observation sheet also noted that R1's toenails or finger nails or both needed clipping on 5 of 6 forms during the period between 12/6/23 through 2/14/24. On 12/27/23 a Home Health Nurse completed an Outside Agency Documentation form and identified resident hygiene as a concern. During the course of an interview R1 confirmed that she was not assisted with showers twice weekly and that there have been occasions where she has called for assistance with no response for up to an hour. The home health documentation reviewed shows that on multiple occasions, including after hygiene was added to R1's care plan, a home health visit was conducted and R1 was observed to be soiled upon their arrival. Based on interviews conducted and the documentation reviewed the allegation of " Staff do not ensure that resident's hygiene needs are being met" is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met. The Department also conducted a review of the admission agreement, pre-placement appraisal and 3 needs and service plans. Based on the documentation reviewed and interviews conducted R1 was not receiving 2 showers per week after hygiene services were added and billed under the needs and service plan therefore the allegation of " Facility is charging resident for services not provided" is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met. Deficiencies are bing cited pursuant to the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties. An exit interview was conducted and a copy of this report, a confidential names list and appeal rights were provided.