complaint·September 23, 2022

It was alleged that the facility has a scabies outbreak. Interview revealed that there were 4 residents in the facility that had been diagnosed with scabies during the time period of the complaint allegation. Review of records for Resident #1 (R1), whom the complaint allegation references, did have a diagnosis of scabies as of 07/01/2020. R1 was prescribed medication for the diagnosed case of scabies. Additional record review revealed this scabies case was not reported to CCL or to Ventura County Public Health, per regulation. Based on record review and interview, the allegation that "facility has a scabies outbreak" is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D.) Executive Director was informed that civil penalties may be assessed at a later date based on Health and Safety Code 1569.49(f). Exit interview conducted, appeal rights discussed, and a copy of this report was issued via email. Regarding the allegation " Resident suffered multiple falls resulting in injuries:" Record review revealed that Resident #1 (R1) had fallen six (6) times during the time period of 06/17/2020 - 08/21/2020. Review of R1's physician's report indicates R1 is non-ambulatory with a diagnosis of dementia. R1 was able to ambulate using a wheelchair. R1 was noted to be able to follow instructions, able to transfer themself and able to communicate their needs. Record review did not reveal that R1 was a fall risk. Although it is possible that R1 had a change of condition, as the care notes dated 07/06/2020 after R1 had returned from the hospital, indicated R1 was "having a hard time walking." No new care assessment or physician's report was completed, so it is unclear whether R1 did have a change of condition or not. Resident Assessment review revealed R1 was independent in most ADLs, including transfers and did not require an escort to ambulate. While record review did indicate R1 had fallen multiple times, there was no documented evidence indicating the falls were sustained as a result of lack of care and supervision. As thus, although the allegation may be valid, based on record review, at this time there is insufficient evidence to prove a violation occurred; therefore the allegation that "resident suffered multiple falls resulting in injuries" is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff did not bathe resident:" During the complaint investigation, LPA reviewed records for R1 and interviewed staff and residents. R1 no longer resided at the facility at the time of the interviews, however resident interviews revealed that showers are currently offered and assisted with on time and on schedule. Record review for R1 indicated R1's needs and service assessment did not include shower assistance, nor did R1's resident pre-placement appraisal indicate shower assistance was needed. However, physician's report did indicate R1 required bathing assistance. Care notes reviewed indicate R1 was showered on 08/13/2020 and 08/15/2020. R1 was hospitalized then R1 moved out of the facility as of 08/21/2020. There was no record of how often R1 was to be assisted with bathing. As thus, although the allegation may be valid, based on record review and interview, at this time there is insufficient evidence to prove a violation occurred; therefore the allegation that "staff did not bathe resident" is deemed UNSUBSTANTIATED at this time. Regarding the allegation "staff illegally evicted resident:" It was alleged that when family arrived at the facility, R1's belongings were packed up and R1 did not return to the facility. Emails between Pacifica Senior Living management members and R1's family were reviewed during the complaint process. Emails reviewed indicate management staff had been in communications Report Continued on LIC 9099-C with R1's family and that alternate placement suggestions had been made for R1's changing care needs 2 days prior to R1 moving out of the facility. The day prior to R1 moving out of the facility, management had exchanged emails indicating "we have not issued a 30 day notice at this time." However, the management team had discussed R1's care needs. Emails indicate R1's family had asked Pacifica to communicate with alternate placement, with the hopes R1 could move to another facility. Care notes indicate R1 moved out of the facility, however it is unclear whether the facility moved the resident out or if the facility evicted R1. Interview with staff revealed that the resident was not evicted to their knowledge, however additional communications with R1's family may have occurred with the Executive Director employed with the facility at that time. The Executive Director left employment effective 08/27/2020 and therefore was unavailable to interview regarding this complaint. Although the allegation may be valid, based on record review and interview, at this time there is insufficient evidence to prove a violation occurred; therefore the allegation that "staff did not bathe resident" is deemed UNSUBSTANTIATED at this time. Regarding the allegation " Staff did not administer medications as prescribed:" It was alleged that R1's 6:00 medications were not administered on time, as they were administered at 06:20. R1 was no longer residing at the facility and had taken their medications with them and therefore unable to be audited during the complaint process. During the visit on 09/23/2022, LPA conducted a medication audit for 3 residents. All 3 of 3 residents' medications reviewed were administered as prescribed. Care notes for R1 did not indicate any discrepancies in medications administered. Communication between the facility and R1's physician was reviewed and did not indicate any medication discrepancies. On 08/14/2020 there was a change in orders indicating medication Quetiapine 25mg was changed from TID to BID (8am and 12noon) and Quetiapine 50mg QPM. However no documentation was able to be reviewed regarding times the medications were administered, nor was there specific dates indicated in the allegation to review what the doctor's orders were at that time. Interviews revealed medications are given on time as prescribed. Although the allegation may be valid, based on record review and interview, at this time there is insufficient evidence to prove a violation occurred; therefore the allegation that "staff did not administer medications as prescribed" is deemed UNSUBSTANTIATED at this time. Exit interview conducted. A copy of the report was provided via email.