LPA received a copy of the C1’s Appraisal/Needs and Services Plan (ANS) dates 01/23/24 that states that C1 has a primary diagnosis of Undifferentiated Schizophrenia and secondary diagnosis of Umbilical Hernia. C1 has ongoing needs for supervision, monitoring, and documentation per the ANS for poor ADL’s. The Licensee did not notate any podiatry care on the ANS although C1’s resident records has a Foot Care Report. C1 does not have an updated Physicians’ Report (LIC 602); last dated 04/17/23 and stated that C1’s capacity for self-care is modified with stand-by assist.

For the allegation, “Staff not assisting client with hygiene” is SUBSTANTIATED. W1 and W2 stated that C1 had poor hygiene, observed black toenails and puss coming from C1’s ear on 07/18/24. ADM said, “Before the nurse came, about two or three hours before, C1 borrowed a cigarette in the morning, could hear and C1 asked for a cigarette early in the day. W1 and W2 transported C1 to the hospital, and on 07/18/24 C1 was admitted to Highland Hospital for an ear infection.

For the allegation, “Staff did not ensure client received medical services” is SUBSTANTIATED. C1 did not have an updated LIC602 to address the primary and secondary diagnosis, and/or Umbilical Hernia since 04/17/23. C1 told W1 and W2 that he/she could not hear on 07/18/24, W1 and W2 assisted C1 medical transportation to Highland Hospital in Oakland, CA that resulted in admittance and a discharge to McClure Post Acute Rehabilitation Center in Oakland, CA. ADM stated that the staff were instructed to call the Licensee first and then to call 911 if instructed to do so for transportation to a local hospital from the facility because some clients are a flight risk. W3 stated that the case managers are the ones who primarily transport the clients to and from appointments. LPA reviewed the facility’s Health Services section of the Program Description, and it states the facility will assist with appointments and transportation.