Complaint·November 22, 2024

Review of documents revealed that Resident #2 (R2) had been diagnosed with presumed scabies and prescribed Permethrin on 02/07/2024. Furthermore, Resident #3 (R3) had been prescribed Permethrin on 1/31/2024. Administrator stated they had not notified CCLD or Public Health due to other residents who were presenting with rashes and itchiness being diagnosed with contact Dermatitis and were waiting for a Dermatologist who was scheduled to visit the facility and test the residents and staff for scabies and confirm if they had scabies. Complaint #29-AS-20240205083319 was substantiated by the Licensing Agency, and on 02/12/2024, the Administrator notified VCPH of the two residents with presumed scabies and possible scabies outbreak and obtained guidance from VCPH to address the outbreak. On 11/09/2023, Resident #1 (R1) had a medical examination by the California Dermatology Institute regarding moderate chronic atopic dermatitis and asteatosis eczema. R1 was prescribed fluocinonide and calcipotriene and was informed of a plan to use moisturizers, hypoallergenic soaps/detergents, and anti-inflammatory topical treatments. R1 was not diagnosed with scabies and was not prescribed Permethrin. On 01/02/2024 and 01/30/2024, Hospice Agency documented reports noted that R1 had severe psoriasis and severe skin dryness which were being treated with prescribed medications and moisturizers daily. On 03/14/2024, LPA received documentation that while hospitalized beginning 02/13/2024, R1 had been tested for skin issues such as scabies. All skin tests of R1 were negative, but the hospital did express that R1 had general skin psoriasis. Based on the information gathered, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation is unsubstantiated. On the allegation: Staff did not meet the resident’s dietary needs. It is alleged that R1 has lost a significant amount of weight while in care at the facility above due to R1 not being fed by facility staff. R1’s Physician’s Report for Residential Care Facilities for the Elderly (RCFE) documents that R1 has no special diet and can feed themselves. The facility Preplacement Appraisal Information for R1 documents that R1 does not need help with eating and has no need for adaptive devices or assistance from another person. The Preplacement Appraisal also documents that R1 strongly dislikes fruits and vegetables while enjoying primarily meat and potatoes. Facility Narrative charting for R1 stated that R1 would refuse to eat dinner or eat very little in the evening on sporadic occasions during their time in care at the facility beginning in 2020. Narrative charting also indicated that R1 would frequently ask for cigarettes, candy, and popcorn rather than eat dinner provided by the facility. Staff interviewed by LPA stated that R1 would sometimes refuse dinner or eat very little dinner while being extremely verbally and physically aggressive to staff. LPA interviewed staff and residents regarding staff handling/delivering food to R1. Continued on 9099-C None of those interviewed had ever observed staff mishandling food or beverages for R1. Staff stated they would pass by R1’s room at least every half hour since R1’s bedroom was up front of the facility near the staff office. On 6/4/2024, R1’s conservator/public guardian stated in an interview with the Licensing Agency Investigations Branch that prior to leaving the facility, R1 appeared healthy and strong, unlike after discharge, where R1 is frail and weak. R1’s conservator/public guardian stated they are aware of the allegation and does not believe there was any neglect from the facility. On 11/15/2024 and 11/22/2024, LPA observed the food service area in the facility and found the food items to be of good quality while served to residents according to the facility meal schedule. LPA observed the food preparation and food supply in the facility as well as delivery of food to residents. Residents interviewed by LPA indicated the food was of good quality, and they had no complaints about the food. All residents interviewed stated to LPA that they are always fed by the facility staff every day. All Staff members interviewed by the LPA stated that residents in the facility are fed appropriate amounts of food on a consistent daily schedule. LPA was provided with pertinent documentation by the facility including a facility menu, meal schedule, and resident documentation relating to any dietary restrictions if applicable. Based on the information gathered, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation is unsubstantiated. On the allegation: Illegal eviction . It is alleged that R1 is not being allowed to return to the facility above. On 02/16/2024, an incident report received by the Licensing agency from the facility above showed R1 was sent to the hospital on 02/13/2024 due to weakness and unresponsiveness. The following day, R1’s resident representative contacted the facility informing them R1 was diagnosed with a fractured femur. Hospital medical records from the visit by R1 on 02/13/2024 state R1 was admitted due to weakness. During the visit, R1 was also found to have a hip/femur fracture. However, the cause was unknown. All Records reviewed by the Licensing agency indicated no reported fall or witness to a fall. R1 is non-verbal, so R1 did not report abuse or neglect, and other residents, including R1’s roommate, would not respond to questions due to their cognitive skill level. There was no police investigation for this case and there were no concerns noted on the medical records or expressed by R1’s conservator. According to facility documentation and interviews by LPA, R1 is under Public Guardianship and was removed from the facility by their Public Guardian while hospitalized beginning 02/13/2024. LPA requested and received both the Notice of Hearing for Conservatorship of R1 and the Capacity Declaration for Conservatorship of R1 documentation from the Superior Court of California. Continued on 9099-C All licensing agency interviews with facility staff and the conservator of R1 indicated that the resident would not be returning to the facility after R1 underwent surgery in the hospital for a broken femur. Although the complaint report allegation indicated it was the facility that did not allow the resident to return, both the Administrator and R1’s conservator/public guardian provided documentation indicating R1’s conservator/public guardian suggested discharging R1 to a Skilled Nursing Facility (SNF) for further rehabilitation and medication adjustments with a doctor onsite. R1’s conservator/public guardian stated that they would not allow R1 to return to the facility after the hospitalization on 02/13/2024, and it was not the facility preventing R1 from returning. R1’s family member and public guardian then began removing R1’s personal belongings from the facility on 03/18/2024. Based on the information gathered, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation is unsubstantiated. Exit interview conducted. Copy of this report provided to the facility.