complaint·February 22, 2023

Regarding the allegation: Staff did not ensure residents received meals in a timely manner It was alleged that staff failed to provide R1 and R2 with meals in a timely manner. Interviews with R1 and R2 claimed that they temporarily had meals delivered to their room, and indicated that meals had been delivered late. It was noted that on Sunday 1/22/2023, breakfast was served late. The Executive Director noted that they had two call-offs in the kitchen, and claimed there was only one server and one cook for the morning. Staff interviews claimed that breakfast was served from 8:00 a.m. – 9:30 a.m., and the Executive Director believed that all residents received meals before 9:30 a.m. on 1/22/2023. It was communicated that meals were considered ‘late’ after 9:31 a.m. However, additional interviews with dining staff claimed that food trays were delivered to residents whom required tray service at approximately 9:35 a.m. Interviews with residents whom often received meals in the room claimed that meals were often delivered after the stated mealtimes. During a visit conducted on 1/24/2023, the LPA was in R1 and R2’s room, when the lunch trays were delivered. Lunch trays were delivered to R1 and R2’s room at 1:30 p.m. Per the meal schedule, lunch is from 12:00 p.m. – 1:00 p.m. Additional resident interviews were conducted during today’s visit, and residents communicated that in general, food has been served past its slated time as described in dining hours. Based on the information obtained in interviews and observations, there is sufficient evidence to support claims that staff did not ensure residents received meals in a timely manner. This allegation is deemed Substantiated at this time. The following deficiencies were observed (See LIC 9099-D.) and cited from the CA Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided. CONT - PAGE 2 Regarding the allegation: Staff did not inform authorized representative of resident's injury It was alleged that Resident #1 (R1) suffered an injury, and staff failed to report it to R1’s responsible party. The investigation revealed that on 12/31/2022, R1 contacted a family member and communicated that their arm would not stop bleeding, and claimed that three (3) weeks prior, a staff had allegedly scratched them on the arm, causing a skin tear. Staff allegedly provided R1 with a band-aid, and on approximately 12/30/2022, Resident #2 (R2) took the band-aid off of R1’s arm, in which it caused the skin to rip open. As a result, R1 contacted their family member, whom then took R1 to urgent care on 12/31/2022. The LPA reviewed medical records, and it was documented that on 12/31/2022, R1 shared with the physician that a staff person at the facility had long nails, and had assisted R1 into bed, causing a skin tear on the right upper arm. There were no additional notes in the medical records regarding a band-aid being placed, or that it was removed, which subsequently caused the skin to rip open. Records review noted that R1 was admitted to this facility on 12/15/2021. R1’s admission’s agreement showed that R1 was self-responsible, and R1 did not indicate an emergency contact nor a responsible party. Staff communicated that R1 was independent of care and did not receive assistance outside of housekeeping and laundry services. An interview with R1 revealed that per R1’s recollection, in early December 2022, they required assistance in the evening, and claimed that two staff persons – a male and a female – assisted R1 with getting into bed. R1 claimed that a staff had ‘gouged’ their nails into R1’s right upper arm while lifting R1 up, which caused the skin tear. R1, nor R2, was able to provide the approximate date for this incident. The LPA interviewed staff whom worked the evening and overnight shift and spoke to the staff that responded to R1’s request. Staff claimed that R1 had asked for assistance to get back into bed, and it required the assistance of two staff. Both staff denied claims of harming R1 and denied claims of scratching R1. Staff stated that R1 did not yell or exclaim in pain that something had happened while assisting R1 into bed. Staff could not recall giving R1 a band-aid. R1 was unable to recall details as to whom provided them with the band-aid, but said they got the band-aid from the staff. R1 was unable to recall if they got the band-aid from the staff that evening, or days following the event. Staff interviews revealed that staff were unaware that R1 had sustained a skin tear and staff denied claims that they caused the skin tear. Staff indicated that although they were responsible for R1 and R2's laundering of their linens, staff could not recollect seeing blood or any other foreign substances on their sheets. CONT - PAGE 3 The LPA reviewed incident reports and care notes related to R1 and R2 and did not find documentation to support claims that R1 was observed with an injury. R1 said when they went to urgent care on 12/31/2022, they did not tell the staff why they were going. Based on the information obtained, there is insufficient evidence to support the claim that staff did not inform the authorized representative of R1's injury. Staff claimed they did not know that R1 sustained an injury. As a result, nothing was reported. In addition, R1 and R2 were self-responsible. Although the allegation may have happened or is valid, there is not enough evidence to prove the allegation did or did not occur, therefore the allegation is Unsubstantiated at this time. Regarding the allegation: Staff did not notify authorized representatives of a Communicable disease outbreak It was alleged that staff did not inform an authorized representative of a COVID-19 outbreak. Specifically for R1, it was alleged that R1’s authorized representative was not notified of the COVID-19 outbreak. The investigation revealed that on 01/03/2023, an email was sent out to the responsible parties of the residents regarding active cases of COVID-19 in the community. The Executive Director also noted that the letter was printed for residents and visitors whom came into the facility. Staff interviews indicated that R1 does not have a responsible party or emergency contact, and as a result, notice of the outbreak was provided to R1 and R2. Records review indicated that R1 was admitted to this facility on 12/15/2021. The investigation revealed that a family member of R1 was made aware of the outbreak when they went to visit R1 and R2, and had not received communication about the outbreak prior to coming to the facility. However, R1’s admission’s agreement showed that R1 was self-responsible, and R1 did not indicate an emergency contact nor a responsible party. Staff indicated that R1 was independent of care and did not receive assistance outside of housekeeping services. The Executive Director admitted that they had previously communicated with R1’s family member but said that R1 was ultimately self-responsible. The staff felt that they had fulfilled their obligation in contacting the responsible parties of residents whom have designated an emergency contact or responsible party. Per records review, R1 does not have an identified responsible party. Based on the investigation, there is insufficient evidence to support claims that staff failed to notify R1’s authorized representative of a communicable disease outbreak. The LPA interviewed R1 and R2, and residents noted that they did not have a responsible party on file and confirmed that they were self-responsible. This allegation is deemed Unsubstantiated at this time. CONT - PAGE 4 Regarding the allegation: Staff did not write an incident report of injury It was alleged that staff failed to write an incident report of R1’s injury. The investigation revealed that on 12/31/2022, R1 contacted a family member and communicated that their arm would not stop bleeding, and claimed that three (3) weeks prior, a staff had allegedly scratched them on the arm, causing a skin tear. Staff allegedly provided R1 with a band-aid, and on approximately 12/30/2022, R2 took the band-aid off of R1’s arm, in which it caused the skin to rip open. As a result, R1 contacted their family member, who then took R1 to urgent care on 12/31/2022. An interview with R1 revealed that in early December 2022, they required assistance in the evening, and claimed that two staff persons – a male and a female – assisted R1 with getting into bed. R1 claimed that a staff had ‘gouged’ their nails into R1’s right upper arm while lifting R1 up, which caused the skin tear. R1, nor R2, was able to provide the approximate date for this incident. The LPA interviewed staff whom worked the evening and overnight shift, and spoke to the staff that responded to R1’s request. Staff claimed that R1 had asked for assistance to get back into bed, and it required the assistance of two staff. Both staff denied claims of harming R1 and denied claims of scratching R1. Staff stated that R1 did not yell or exclaim in pain that something had happened while assisting R1 into bed. Staff interviews revealed that staff were unaware that R1 had sustained a skin tear and staff denied claims that they caused the skin tear. The LPA reviewed facility incident reports and care notes related to R1 and R2 and did not find documentation to support claims that R1 was observed with an injury. R1 said that when they went to urgent care on 12/31/2022, they did not tell the staff why they were going. Based on the information obtained, there is insufficient evidence to support the claim that staff knowingly failed to write an incident report. Staff claimed that they did not know that R1 sustained an injury. As a result, nothing was reported. Although the allegation may have happened or is valid, there is not enough evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.