Complaint·June 7, 2023

(continued from 9099) Regarding the allegation: Facility did not bathe resident. During an interview with R1, they stated they were supposed to be bathed three times per week in the evening. However, R1 stated sometimes they only receive one or two showers per week. Staff indicated R1 was supposed to be bathed three times per week in the evening and if R1 did not get bathed the morning shift would receive complaints from R1. R1's Needs and Services Plan dated 4/28/2022, indicates R1's bathing schedule was Monday, Wednesday and Friday during the evening shift. LPA had requested documentation from the administrator regarding R1's bathing as LPA was aware the previous facility administrator had staff start logging when residents were bathed or if they refused to be bathed. Since R1 is no longer at the facility R1's file was closed. The administrator was unable to retrieve the bathing logs which were noted in end of shift reports for all residents. The current administrator closely monitors the end of shift reports to watch for concerning incidents and to ensure needs are met. Therefore, the allegation the facility did not bathe resident is deemed substantiated at this time. Regarding the allegation: Facility is not responding timely to resident's pendant calls for help. During an interview with R1, they stated sometimes it can take staff up to an hour to respond to their pendant call. R1 stated usually it was approximately 20 minutes for staff to respond but sometimes staff would arrive right away. R1 thought that was due to staff location in the facility when they used their pendant. LPA interviewed staff who stated R1 had complained on several occasions about pendant call response times. LPA was not able to review pendant call response times as the administrator was not able to obtain the response logs for August 2022. Therefore, findings are based on interviews with R1 and staff. The allegation facility is not responding timely to resident's pendant calls for help is deemed substantiated at this time. The administrator indicated they have improved on response times since 2022 as they have conducted pendant response time training with all staff. LPA reviewed current pendant response times which appear to run between one to five minutes with a couple outliers at ten to fifteen minutes but those are still within the facility expectations for call response times. Pursuant to Title 22 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 provided to the administrator. (continued from 9099-A) Regarding the allegation facility changed resident's medication without obtaining permission: LPA reviewed medication records. All medications were prescribed by R1's physician. R1 stated they thought their injectable medication was changed by facility staff. Facility staff stated R1's physician prescribed all medications and their pharmacy sent the medications to the facility. The appearance of the injectable medication had changed but it was the same medication. Based on records reviewed and interviews the allegation facility changed resident's medication without obtaining permission is deemed Unsubstantiated at this time. Regarding the allegation facility did not assist with the self-administration of the resident's medication: LPA reviewed medication records, interviewed staff and interviewed R1. There was concern which was addressed with R1 by the prior administrator and health services director. R1's hands were very shaky and they were concerned R1 would no longer be able to inject their injectable medication. R1 stated the prior health services director and the medication technicians helped with their injectable medication by performing hand over hand assistance. LPA confirmed with the lead medication technician that they performed hand over hand assistance with R1's injectable medications. R1 did not go without any of their medications. Therefore, based on record review and interviews, the allegation facility did not assist with the self-administration of resident's medication is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report and appeal rights were provided to the administrator.