complaint·February 15, 2023

Regarding the allegation: staff do not respond to residents’ calls for assistance On 04/25/2022, starting at 1:48 p.m., LPA interviewed Resident #1 (R1). Interview with R1 revealed that they have a pendant that continuously breaks. R1 stated, on the days that the pendant is functioning properly, it takes about 20 minutes or more for staff to help. When the pendant is not working, R1 indicated that staff takes the pendant button to fix it but don’t return it for a few days later. Interview with Executive Director (ED) Kortnie Spitznogle on 04/25/2022, starting at 2:45 p.m. revealed that R1 has a working pendant but they continuously push it when help does not arrive. It was communicated that staff had it replaced multiple times because R1 pushes it too hard it breaks. Staff indicated that R1 gets handed a new pendant within a day or two. R1 is on a 2-hour check-up, based on R1’s Needs and Service Plan. In addition, the facility Business Office Manager (BOM) conducts a monthly test on all pendants for servicing. On 2/15/2023, starting at 12:00 p.m., LPA Smith reviewed the SMARTcare Alert Call Button report for Resident #1 (R1). Regarding R1, it was indicated that out of the four (4) instances where R1 pressed their pendant in April 2022, there was one (1) alert that failed to receive a response, and the other three (3) alerts were responded to in a timely manner. However, R1’s pendant button was reportedly to be regularly in disrepair. As such, R1 is unable to call for assistance as needed. As a result, the provided logs may not fully represent the time(s) in which R1 required assistance, or when R1 was without a button and still required assistance. R1 also reported that they would sometimes have to yell for assistance. On 01/23/2023, LPA Ascencio reviewed the SMARTcare Alert Call Button report for three (3) different residents. Review of the call button report revealed that from 11/06/2022 through 12/02/2022, there was seventeen (17) alert button announcements that have elapsed the company’s fifteen (15) minute policy. Further review of the SMARTcare report also revealed that there were five (5) alerts that were never responded to from 11/06/2022 – 12/02/2022. Based on the information from the investigation, there is sufficient evidence to support the claim that staff are not responding to residents’ calls for assistance in a timely manner. A similar complaint was substantiated on 10/25/2022. Based on record review and interview, the allegation is substantiated at this time. CONT 9099-C Regarding the allegation: Resident's diapering needs are not met in a timely manner. On 04/25/2022, starting at 1:48 p.m., LPA interviewed R1. Interview with R1 revealed that when R1 calls staff for toileting needs, staff show up to help 20-30 minutes later, or don’t respond at all. R1 stated they have incontinence issues and would prefer to use the restroom but cannot make it due to their physical limitation. Lastly, R1 added they rely on staff for toileting need and incontinence assistance. On 01/31/2023, starting at 12:05 p.m., review of R1’s Needs and Service Plan revealed that R1’s bathing, toileting, and bowel incontinence require total assistance. Review of Hospice records on 01/31/2023, starting at 12:40 p.m. revealed that on 06/06/2022, Hospice Representative found R1 saturated in urine, dry stool in groin area, and stool under draw sheet. Interview with Hospice Representative on 06/24/2022, starting at 9:45 a.m., confirmed that R1 was found saturated in urine and stool. Although there was insufficient evidence for R1s need not being met, interviews with resident and outside agency revealed that residents diapering need are not met in a timely manner as R1 was found saturated in urine and dry stool in groin area. Therefore, the allegation resident’s diapering needs are not met in a timely manner are 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 809-D): Exit interview conducted. Civil penalties assessed. A copy of the report, along with appeal rights, were provided.