complaint·July 31, 2023

Regarding the allegation: Untrained staff It was alleged that the staff that worked in the memory care unit were not adequately trained to manage residents with a diagnosis of dementia. As defined by Health and Safety Code 1569.626(a)(1) direct care staff must have eight (8) hours of in-service training per year on the subject of serving residents with dementia. For newer staff, staff must receive twelve (12) hours of initial dementia care training. During today’s visit, the LPA audited staff training records for five (5) staff from 2022. Out of the five files reviewed, four out of five staff failed to have the required hours of dementia training as required per Health and Safety Code. Based on the information obtained in the file audit, there is sufficient evidence to support the claim that all staff were not fully trained as it related to residents with a diagnosis of dementia. This allegation is deemed Substantiated at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D). Exit interview conducted. A copy of the report and appeal rights were issued. Page 2 1. Regarding the allegations: Staff failed to assess the resident in care and 2. Staff failed to meet resident's medical needs It was alleged that the facility failed to assess R1’s medical needs, such as completing a UTI test, assessing whether R1’s medication regimen was working, medication crush orders, or assessments into R1’s causes of behavior. In addition, it was alleged that the facility failed to assess the resident in care. As the facility is a non-medical facility, the majority of the requests would have been fulfilled by R1’s primary care physician (PCP). In addition, per regulation, a facility is not required to have nursing staff, as the facility is not capable or required to provide medical care. The facility does not have the capacity to run a ‘UTI test’ or other medical or pain assessments. As R1 had an assigned PCP, requests had to go through the PCP. If residents at this community required a doctor’s appointment, they would have to travel outside of the community to attend a doctor’s appointment. Records review revealed that the facility regularly communicated with R1’s primary care physician (PCP) regarding R1’s increased agitation and aggressive behavior. Requests dated 2/3/2022 documented that R1 exhibited agitation and exit-seeking behavior. R1’s PCP responded with ordering an increase to R1’s Seroquel as an attempt to manage the behavior. Notes on 5/31/2022 documented that R1 was having trouble taking their medication, which was increasing R1’s agitation. As such, staff requested a time change as to when R1 took the medication to increase R1’s likelihood of taking the medication. R1’s PCP agreed and wrote an order for R1’s medication to be taken at a different time. On 6/9/2022, after the facility communicated that R1 continued to display aggression and biting behavior towards staff, R1’s PCP again recommended a medication increase. A follow up note to R1’s PCP on 6/22/2022 again resulted in R1’s PCP recommending a medication adjustment. Throughout this time, interviews indicated a 1:1 companion was needed for R1 for additional oversight and safety monitoring, as R1’s behaviors had not improved. As such, the facility attempted multiple strategies towards decreasing R1’s agitation. There were multiple requests written to R1’s PCP in June due to R1’s increased agitation and physical aggression towards staff. Records indicated that on 6/6/2022, R1’s PCP recommended a psychiatric evaluation, and indicated that it needed to be scheduled by R1’s responsible party, not the facility. On 6/22/2022, R1’s PCP again documented that a psychiatric evaluation was needed once staff informed the PCP that R1 continued to bite staff. Page 3 The note stated Psych consult ASAP! Tell [family member]. On 9/27/2022, after communicating to R1’s PCP that R1 was exhibiting aggressive behavior, R1’s PCP documented that they had asked for a psychiatric evaluation and wrote that the family needed to request it ASAP. R1’s PCP noted the same direction on 10/13/2022, re-iterating that the family needed to schedule a psychiatric evaluation. Staff continued to inquire with R1’s PCP about the best course of action to manage R1’s behaviors. Staff interviews indicated that they attempted to provide contact information for different psychiatrists, and staff communicated that they too attempted to call locations. However, staff indicated that when it comes to referrals, families are typically responsible for schedule the requested evaluations. Records titled ‘Gables of Ojai Routine Check Report’ represented charting notes specifically of R1. Records demonstrated that staff documented R1’s mood, behavior, specific outbursts, incontinence, and willingness to take medications on a daily basis. Staff also documented times that R1 refused care, such as being changed and taking showers. Staff interviews stated that when R1 would refuse care, staff would try multiple intervention methods to ensure that resident needs are tended to in a timely manner. Staff claimed that if they are unsuccessful with assisting R1, they will elevate the concern to management to mitigate the challenge or will enlist the assistance of another caregiver. Lastly, although there was a claim that R1 had lost a tooth and it was provided to R1’s family, there was insufficient evidence obtained in staff interviews or records to corroborate this claim. Staff were unaware of this occurrence. Records reviewed indicated that on 9/4/2020, staff informed R1’s PCP that R1 had a broken tooth on the upper left side of R1’s mouth, and notes reflected that R1 had a 2 p.m. appointment that day. Otherwise, no other mention of R1 having any missing or broken teeth. Based on the investigation, there is insufficient evidence to support the claims that the facility failed to meet R1’s medical needs, nor that the facility failed to assess R1. Records and interviews indicated that facility was in regular communication with R1’s PCP and took direction from R1’s PCP to best manage R1’s care as instructed. The facility implemented multiple medication changed in an attempt to manage R1’s behaviors. Staff attempted to be involved with the researching and scheduling of a psychiatric evaluation, but the responsibility ultimately was on R1’s responsible party. The allegations Staff failed to meet resident's medical needs and Staff failed to assess the resident in care are Unsubstantiated at this time. Page 4 3. Regarding the allegation: Due to lack of supervision, resident escaped from facility It was alleged that R1 eloped from the facility. A specific incident referenced took place on 8/4/2022, when R1 allegedly was in front of the memory care building and staff were unable to get R1 to return to the building. A physical plant tour of the memory care unit and staff interviews supported claims that although the door is equipped with delayed egress, should residents egress out the front door, staff must follow the resident and use non-physical intervention methods to guide the resident back into the communities. Interviews and a review of the facility ‘Incident Report’ revealed that staff attempted to coerce R1 back into the community, to which R1 refused. R1 successfully egressed to the front patio/lawn of the memory care unit. Staff called management over to assist with guiding R1 back into the memory care unit, but R1 refused to go. Staff ultimately called R1’s responsible party to help with assisting R1 back into the community. Staff indicated that R1 did not leave the building due to lack of supervision, as staff were aware that R1 was at the front entrance, but in attempts to guide R1 away from the door, R1 refused. Staff felt that they employed multiple intervention methods and supports in an attempt to assist R1 back into the community. Based on the information obtained in interviews and records review, there is insufficient evidence to support the claim that due to lack of supervision, R1 eloped from the facility. This allegation is Unsubstantiated at this time. 4. Regarding the allegation: Staff failed to administer resident's medication as prescribed It was alleged that staff were unsure as to whether R1 was taking their medication or not. In addition, it was alleged that the staff failed to put a crush order in place, nor did the staff request a medication review by the pharmacy. Staff interviews confirmed that R1 would regularly refuse to take their medications, and that staff would communicate this concern to R1’s primary care physician. Staff also alleged that they were documenting the times and dates in which R1 would refuse to take medication. The LPA reviewed R1's electronic Medication Administration Record (eMAR) and noted that staff indicated all the times in which R1 would refuse medication assistance. Staff also alleged that they were informing R1's responsible party of these instances, as it was a frequent occurrence. Page 5 Records titled ‘Gables of Ojai Routine Check Report’ represented charting notes specifically of R1. Records demonstrated that staff documented R1’s mood, behavior, specific outbursts, incontinence, and willingness to take medications on a daily basis. Records review revealed that the facility regularly communicated with R1’s primary care physician (PCP) regarding R1’s challenges with adhering to a medication regimen. Requests dated 2/3/2022 documented that R1 exhibited agitation and exit-seeking behavior. R1’s PCP responded with ordering an increase to R1’s Seroquel as an attempt to manage the behavior. Notes on 5/31/2022 documented that R1 was having trouble taking their medication, which was increasing R1’s agitation. As such, staff requested a time change as to when R1 took the medication to increase R1’s likelihood of taking the medication. R1’s PCP agreed and wrote an order for R1’s medication to be taken at a different time. On 6/9/2022, after the facility communicated that R1 continued to display aggression and biting behavior towards staff, R1’s PCP again recommended a medication increase. A follow up note to R1’s PCP on 6/22/2022 again resulted in R1’s PCP recommending a medication adjustment. Throughout this time, the staff kept in regular communication with R1’s PCP, who was overseeing R1’s medication regimen. Today, the LPA conducted a medication audit of five (5) residents in the memory care unit. No medication errors were observed during the medication audit. Staff documented the times residents would refuse medication in the electronic Medication Administration Record (eMAR). Based on the information obtained in the medication audit, interviews, and record review, there is insufficient evidence to support the claim that staff failed to administer R1’s medication as prescribed. This allegation is Unsubstantiated at this time. 5. Regarding the allegation: Facility failed to provide resident's records to authorized representative It was alleged that R1’s responsible party had requested R1’s full records, which were allegedly heavily redacted and/or edited. It was stated that R1’s responsible party had received minimal information. Staff interviews supported claims that the facility had provided R1’s family with R1’s complete file. Staff denied claims that information was redacted, edited, or removed. Staff claimed that R1’s responsible party was provided with documents during the in-person care conference, and indicated that all documents were provided as requested. Based on the information obtained, there is insufficient evidence to support the claim that the facility failed to provide resident's records to authorized representative. This allegation is deemed Unsubstantiated at this time. 6. Regarding the allegation: Facility doesn't return phone calls It was alleged that the facility failed to return the phone calls from R1’s responsible party as it related to R1’s care. Various statements were obtained related to this allegation; staff indicated that they oftentimes had to call R1’s responsible party to provide updates and indicated that R1’s family did not return the phone calls from the staff. However, R1’s responsible party indicated that they only received phone calls to obtain payment, and that the facility did not return their calls related to R1’s care and behavior. In general, staff interviews indicated that families either called the front desk and calls were then transferred over to the appropriate parties or to the memory care unit, or families could directly call the memory care unit if need be. It was further communicated that the receptionist would ensure that calls were sent to the requested parties and not only taking messages, as they understood the importance of the call and did not want the messages to get lost. In addition, residents raised no concerns as it related to receiving calls from loved ones if they called the facility. Based on the information obtained, there is insufficient evidence to support the claim that the facility failed to return phone calls. This allegation is deemed Unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.