complaint·April 1, 2022

...Continued from LIC 809... It was alleged that Resident's room was not properly maintained and R1’s care had been neglected during their time at the facility as there was a terrible smell coming from inside the room. It was reported that Resident 1’s (R1’s) room was unkept and the room smelled like urine and feces. It was further reported that inside the room were a water bottle that had mold, soiled clothes stacked in the tub, and rotten trash that was not taken out. Interviews with R1’s family members revealed that they were ‘appalled at the state of their room’. Interviews with the staff revealed that housekeeping is done once a week and reported that ‘sometimes caregivers will call housekeeping if a resident’s room is too dirty in between’. Interviews with residents confirmed that housekeeping is done once a week. Additionally, interviews with residents revealed that everything gets charged, ‘if it is not in your care plan, they will add it to your bill’. Correspondingly, interviews with random resident family members revealed that when they have previously visited, the room is not messy, although it could be a bit cleaner. Also, Interviews with random resident family members revealed that they had visited the resident and the smell of urine was lingering around and were concerned as they stated, ‘the bed is still wet while they’re lying there…’. They had previously requested a fan to dry out the mattress because they were only making the bed but not drying it out. Interview with the ED revealed the facility was not short staffed due to the pandemic and if they were short staffed, agency staff came in and helped out when needed. Additionally, the level of care displayed what services came standard. As far as laundry and taking out the trash, that is a standard service that comes included in the level 4 care plan. Furthermore, record review revealed photos that of which displayed clothes all over the living room, mold on the straw of R1’s water bottle, and soiled clothes in the bathtub. Per Admissions Agreement signed on 1/17/2020, it states on page 5 of 44, under bullet point 2-Our Services, ‘we provide the following standard services for the stated monthly rate: weekly linen laundry service and cleaning of apartments’. However, R1’s room was not properly maintained while living at the facility. Based on the information and records obtained and reviewed, the allegation of “Resident's room was not properly maintained” is deemed Substantiated at this time. Additionally, based on interviews and record review, the allegation that “Resident was not provided a comfortable accommodations” is deemed Substantiated at this time. ...Continued on LIC 809C... ...Continued from LIC 809C... It was also alleged that resident was not properly groomed while in care. Information gathered during the course of the investigation revealed R1 was admitted to the facility on 1/18/2020. Per R1’s Resident Functional Needs Assessment Pre-Move in, dated on 1/14/2020, noted R1 to require limited assistance, two (2) times per day for grooming. Limited Assistance under grooming states ‘requires assistance with preparation of grooming materials for grooming and/or minimal assistance grooming’. Furthermore, the Resident Functional Needs Assessment Move In, dated 1/23/2020 maintained the same level of care under ‘Grooming’ as limited assistance, two (2) times per day as the Resident Functional Needs Assessment Change in Plan dated 6/02/2020. Additionally, per Physicians Report dated 6/23/2020, it stated R1 required assistance of another person for basic ADL’s including bathing, dressing, grooming, toileting, managing own cash resources, and was at risk if allowed direct access to personal grooming and hygiene items. Per interviews conducted, basic grooming is part of level 4 care plan, which is the level of care R1 was receiving while living at the facility. Record review of photos portrayed R1 had been unkept and ungroomed for months prior to moving out. Based on all information gathered during the course of the investigation, the above allegation, “Resident was not properly groomed while in care” is deemed Substantiated at this time. It was also alleged that Resident's laundry needs are not being met while in care. It was reported that inside the room were soiled clothes stacked in the bathtub. Per interviews conducted, it was revealed that laundry includes staff taking the clothes, washing, drying, and folding, and it is up to the resident to put clean folded clothes away. However, per R1’s Physicians Report dated 1/20/2020, R1’s primary diagnosis included: deconditioning, general weakness, gait, balance disorder, and due to a heart attack years before, R1 had paralysis on the left side. Furthermore, R1 required one person assist with ADL’s including bathing, dressing, and toileting needs. After laundry was brought back to R1’s room, it was to be put away by the care staff. Interviews with the ED revealed laundry being put away by care staff was a standard service that came with the level 4 care plan. However, record review revealed photos displaying clothes in the bathtub and on the sofa. Based on the information and documentation obtained and reviewed, the allegation of “Resident's laundry needs are not being met while in care” is deemed Substantiated at this time. ...Continued on LIC 809C... ...Continued from LIC 809C... It was further alleged that Resident was charged for services not received. It was reported that the facility was responsible for R1’s grooming, laundry, and tidying up the room, and the facility was sending bills reflecting those items in care. Interview with the ED revealed grooming, putting clean laundry away, and throwing out the trash was part of R1’s care plan. Per Physicians Report dated 6/23/2020, it stated R1 required assistance of another person for basic ADL’s including bathing, dressing, grooming, toileting, and managing own cash resources. And Resident Functional Needs Assessment Change of Condition dated 6/02/2020, stated, ‘requires two (2) person on all transfer for safety.’ Thus, R1 was unable to complete any of those tasks themselves and required the assistance of the care staff. Hence, R1 was admitted to the facility with the care plan that best suited them at the moment which included grooming, laundry, and throwing out the trash as part of the standard services offered for that level of care plan. Furthermore, records revealed photos which displayed R1’s room to have soiled clothes stacked in the tub, rotten trash that was not taken out, and R1 to be ungroomed. Based on the information and records obtained and reviewed, the allegation of “Resident was charged for services not received” is deemed Substantiated at this time. Pursuant to CCR, Title 22, Division 6, Chapter 8, the following deficiencies are cited (Refer to LIC LIC9099-D). Exit interview conducted. Citation issued. Appeal Rights discussed. A copy of report provided via email. ...Continued from LIC 809C... It was alleged that Resident's dental needs are not being met while in care. It was reported that R1 lost a tooth due to lack of dental hygiene while at the facility. Per interviews conducted, all medical appointments are made by either the resident’s Power of Attorney (POA) or family members. Furthermore, the facility will only assist the residents with transportation to and from their medical appointments. Additionally, per Admissions Agreement signed on 1/17/2020, it states on page 5 of 44, under bullet point 2-Our Services, ‘we provide the following standard services for the stated monthly rate: assisting in arranging your transportation to medical and dental appointments…’.However, arranging the actual medical and/or dental appointment would be up to the POA or family members. Based on the information and documentation obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “Resident's dental needs are not being met while in care”. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted. No citations issued. A copy of report provided via email.