complaint·May 22, 2025

Report Continued from LIC 9099... It was alleged that staff do not ensure residents incontinence needs are met. It was reported that a resident may have been wearing the same diaper since discharge from the hospital. Interviews conducted with staff revealed that incontinent residents are changed at least three times per day, and all other residents are checked and changed as needed. Staff also stated that residents are alert and able to notify staff when they require assistance with changing. Furthermore, staff reported that no residents have complained about being left wet for extended periods of time. Additionally, 4 out of 4 residents interviewed expressed no concerns regarding the frequency of diaper changes or the assistance provided for their incontinence needs. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegation of “staff do not ensure residents incontinence needs are met”. Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview conducted. Report was reviewed and copy provided. Report Continued from LIC 9099... It was alleged that staff did not ensure resident had a physician’s order for bed rails. It was reported that Resident #1’s (R1’s) bed is equipped with bed rails; however, the care plan has not yet been approved by a physician. Records reviewed and interviews conducted revealed that R1 does not have a physician’s order authorizing the use of bed rails. Staff stated that the bed had been placed in the room prior to R1’s admission to the facility. Additional staff interviews further revealed that they had not reviewed R1’s file to verify if a physician’s order for bed rails was present. Furthermore, staff indicated they were currently waiting for home health to send a copy of the care plan confirming that R1 is approved to use a bed with rails. Based on record review and interviews conducted, the Department has sufficient evidence to say the alleged violation occurred. Therefore, allegation “staff did not ensure resident had a physician’s order for bed rails” is deemed Substantiated at this time. It was also alleged that staff are not adequately trained. It was reported that facility staff is inadequate in providing care to the residents. Records reviewed revealed that facility staff have not yet completed the required 20 hours of annual training as specified by regulations. The Administrator stated that staff have completed the 20 hours and also participate in monthly refresher trainings. However, during staff interviews, employees reported having completed some training but were unsure of the total number of hours or whether it met the 20-hour requirement. Furthermore, although the facility maintained a designated training binder, the LPA was unable to verify compliance with the required training hours for the past 12 months. Based on record review and interviews conducted, the Department has sufficient evidence to say the alleged violation occurred. Therefore, allegation “staff are not adequately trained” is deemed Substantiated at this time. It was also alleged that resident has missed medications and staff do not ensure residents medication needs are being met. It was reported that the resident is not receiving all prescribed medications, and some medications are missing and not being administered at all. Records reviewed revealed that R1 had twelve new prescriptions added to their medication list. According to inpatient discharge instructions dated 03/24/2025, R1 was prescribed several new medications, including acetaminophen–oxycodone, miconazole topical cream 2%, pantoprazole 40 mg, polyethylene glycol 3350, and selenium sulfide topical 1%. Report Continued on LIC 9099C... Report Continued from LIC 9099C... However, these medications are not listed on R1’s Centrally Stored Medication and Destruction Record (CSMDR). Staff interviews indicated that R1 was being administered gabapentin, and staff believed that additional pain medications were unnecessary, as they considered gabapentin sufficient for pain management. However, R1 has physician orders for PRN (as-needed) medications for pain, which include acetaminophen–oxycodone (1 tablet every 4 hours as needed) and acetaminophen 650 mg (2 tablets every 8 hours as needed), both specifically prescribed for pain management. Furthermore, during the medication review on 04/14/2025, the LPA did not observe any missing medications stored centrally, as the facility did not have medications available on-site. Based on record review and interviews conducted, the Department has sufficient evidence to say the alleged violations occurred. Therefore, allegations “resident has missed medications” and “staff do not ensure residents medication needs are being met” are deemed Substantiated at this time. It was further alleged that staff are not meeting resident's needs. It was reported that resident was recently discharged from the hospital, and facility staff had not checked R1’s blood sugar levels. A review of R1’s inpatient discharge instructions, dated 03/24/2025, revealed that R1 was to have their glucose checked twice daily for 30 days. Records reviewed and interviews conducted indicated that R1’s glucose levels had been monitored; however, when inspecting the documentation, it was found that the glucose readings were recorded from 12/14/2024 to 02/03/2025. Staff confirmed that all readings had been documented but indicated that they were unaware that R1's glucose levels needed to be checked twice daily for 30 days after being discharged from the hospital. Furthermore, although staff had been checking R1’s glucose levels daily prior to the hospitalization, they failed to continue monitoring R1’s glucose levels after discharge, as per the doctor's orders. Based on the information obtained and reviewed, the Department has sufficient evidence to say the alleged violation occurred. Therefore, allegation “staff are not meeting resident’s needs” is deemed Substantiated at this time. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.