complaint·May 21, 2025

On the allegations, “Facility staff not meeting resident's incontinence care needs and Facility staff did not clean feces off baseboards in resident's room”; it is the concern of the reporting party that on 06/20/23, Resident #1(R1) had a bowel issue in the morning and that at 1:00 p.m. five hours later R1 was observed to be left with feces on their back, as well as on the base boards. RP further reported that Photos were submitted to the Department. One of the photo’s was a photo of the back of an individual without a shirt with brown streaks and a lump of what appears to be poop. The Photo does not have a date or time stamp. A second photo of what appears to be a yellow wall, and white baseboard with several brown stains was submitted. To investigate the allegation, the LPA conducted interviews with Staff, residents, and resident’s family members/authorized persons; however, the individuals were not present during the incident and therefore, could not offer sufficient information regarding whether it did or did not occur. Interviews with staff revealed that most of the staff that are currently in the Memory Care Unit of the community were employed within the past year, they were not at the facility in 2023, and that they check/change on residents every 2 hours or as needed. If staff notices rooms to be unkept they will clean them. Interview with a care giver in the MC unit that has been at the facility for about three years revealed that they do not have knowledge of any incident involving R1 having feces on them or their baseboards and further revealed that residents are changed right away. Interviews with family members revealed that they have witnessed residents in the common areas that appear to be soiled, they will let the staff know and staff will go change them, and although they can assume how long they have been soiled for based on their appearance they do not know how long residents were soiled for. Interviews with residents revealed that they do not have any concerns about the care being provided, with one resident stating that staff assist residents right away. Based on Interviews there is insufficient evidence to support the above allegations. Therefore, the allegations are being deemed Unsubstantiated at this time. Report will continue on LIC9099-C, 3rd page. On the allegation, “Facility staff not providing quality meals to residents”; it is the concern of the reporting party that the facility does not serve "senior friendly food," the food is always cold, and most residents are unable to hold it, cut it or chew it and that certain items are much too spicy. Residents interviewed revealed that they do not have any concerns regarding the food. On 03/17/25, 04/24/25, 04/29/25, and 05/12/25, the LPA observed lunch, or dinner or both and the LPA found the food items on the menu to be of good quality while served to residents. On those dates, the LPA observed residents eating by themselves and with staff’s assistance. The facility has a main kitchen in Assisted Living of the facility off the main dining room. The resident’s food in the Memory Care unit gets delivered in a food cart, usually about 20 to 30 minutes before it is lunch or dinner time. Then the food gets placed on a food steamer that is turned on to keep the food warm for the residents. There is also a microwave if the food needs to be heated more. Staff interviews revealed that they are aware of what residents can eat and which residents have dietary restrictions. The 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 interviews and observations there is insufficient evidence to support the above allegations. Therefore, the allegation is being deemed Unsubstantiated at this time. Exit interview conducted, copy of this report issued. On the allegation of, “Facility staff did not shower resident per admission agreement,”; it is the concern of the reporting party that upon admission to the Memory Care Unit in March 2023, facility staff did not shower Resident #1 (R1) for the 1st 10 days R1 was there. RP also reported that “R1 was not on the (shower) schedule". Per R1’s Admission Agreement, signed and dated 3/3/23, pg. 30 Exhibit B under Care Fees “The Community utilizes a resident assessment form to help determine the individual’s functional capabilities, physical status, mental condition, and social factors and the amount of assistance an individual may need with activities of daily living. This tool is divided into categories (for example, bathing, dressing, eating, etc.) and each individual’s needs are evaluated for each category.” Based on R1’s Resident Assessment Form dated 03/09/2023, R1 scored 12 points in the bathing category which indicated that they required stand-by assistance for all showering/bathing needs (2x per week). Additionally, R1 had a score of zero (0) for Hospice and outside providers. Interview conducted with the Wellness Director on 04/24/25, revealed that when R1 was admitted to the facility, they were admitted on Hospice and R1 received showers from Hospice and not the staff and R1 was never on the shower schedule. The community was not able to provide Hospice records for showers provided to R1 for March 2023. On 05/20/2025, Administrator Kenneth Mahler confirmed telephonically to LPA Cortez that when a Hospice Agency provides shower services to the resident, Hospice fully takes over for the showers. Based on Interviews and file review, there is sufficient evidence to prove that the allegation " Facility staff did not shower resident per admission agreement," occurred. Therefore, the allegation is Substantiated. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency was observed and cited during the visit (See LIC-9099-D). Exit interview conducted. A copy of the report and appeal rights were provided.