complaint·May 4, 2023

(continued from 9099, page 1) Regarding the allegation: Facility staff are not reporting all of resident's falls During LPA's review of facility records for Resident 1 (R1), LPA found in the Care Notes that R1 had falls on 7/17/2022, 7/19/2022, 7/20/2022, and 7/28/2022. R1 was taken to the urgent care on 7/19/2022 and the hospital on 7/28/2022 by R1's family. Records indicate R1's family and physician were notified of these falls, however none of these falls were reported to Community Care Licensing (CCL). Therefore, this allegation is deemed substantiated at this time. Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued. (continued from 9099-A, page 1) Regarding the allegation: Staff over-medicated resident to prevent resident from ambulating. LPA reviewed medication records and care notes for resident 1 (R1). Medications appeared to be given as prescribed. R1 was prescribed some medications that could make R1 seem sedated at times. If staff observed R1 seemed overly drowsy, certain medications would be withheld and R1's physician was notified. Staff would request direction from R1's physician regarding administration of medications that may make R1 drowsy when R1 seemed overly tired or sedated. There was no indication R1 was being given these types of medications when not needed. Therefore, this allegation is deemed unsubstantiated at this time. Regarding the allegation: Staff did not assist resident with ambulating as needed. LPA reviewed records for R1 and resident 2 (R2). R1's assessments and individualized service plan did not indicate R1 needed escorting or assistance from staff to ambulate. R1 was known by staff to be quite independent. R2's assessments and individualized service plan did not indicate a need for escorting. The memory care director had updated R2's service plan on 8/31/2022, however R2's family had not had an opportunity to review the proposed new services which included escorting to meals. In addition, while the MCD felt escorting was recommended it was not deemed an urgent change. Since escorting was not deemed urgent and the MCD still needed to go over the new service plan with R2's family, the escorting had not been implemented on 9/1/2022 when R2 fell at the facility. Therefore, this allegation is deemed unsubstantiated at this time. Regarding the allegations: Staff did not assist resident with showering as needed. and Staff did not assist resident with changing undergarments as needed. LPA reviewed facility assessments and individualized service plans for R1. It was found that R1 was capable of changing clothing, using the bathroom and taking a shower on their own; R1 was said to only need reminders, set up and prompting. During interviews with staff it was stated that although R1 was in the memory care unit, R1 was very independent for most things. R1 resisted taking a shower, even if staff tried to assist R1 in the shower. R1 would become combative with staff. They tried different techniques to encourage R1 to take a shower. When R1 needed to change clothing or undergarments, staff would set out clean garments for R1 to put on but R1 did not want or need assistance with changing garments. Therefore, these allegations are deemed unsubstantiated at this time. Regarding the allegation: Facility staff are distracted by their personal phones and not meeting the needs of residents. During LPA's interviews with the MCD, staff and a witness, it was stated that more than one staff in the memory care unit had been observed browsing their personal cell phones. The MCD notified staff they should not be on their personal phones while working. There was no evidence that staff failed to meet residents' needs. There is no regulation preventing the use of personal phones by staff. Therefore, this allegation is deemed unsubstantiated at this time. Exit interview conducted, appeal rights discussed, and a copy of this report issued.