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13 | Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint investigation visit regarding the allegations listed above. LPA discussed the purpose of the visit with Executive Director Sanjay Kabadi.
The investigation consisted of: On 12/19/2023, LPA conducted a physical plant inspection of common areas and resident (R1's) room; photographs of R1's room were taken. Staff (S1- S7) and residents (R1-R3) were interviewed. The following documents were reviewed/obtained: Identification and Emergency Information/Face Sheet, Admission Record, Preplacement Appraisal Information, Physician's Report (11/23/2022), Personal Service Plan [12/1/22, 1/25/23, 7/14/23, & 8/7/23], Hospice Care records, Hospice Collaboration Notes, and resident and staff rosters. During today's visit, LPA conducted a physical plant inspection and interviewed resident (R4- R7), and Health and Wellness Director for an update on resident (R1).
NOTE: Resident (R1) moved out on 12/21/2023.
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| Substantiated | Estimated Days of Completion: |
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32 | Allegation: Staff do not ensure that resident's incontinence care needs are met. It is alleged that staff did not meet the incontinence needs of bed bound resident (R1). According to reporting party, facility staff were not changing R1's incontinence diaper, resulting in the resident lying in urine and feces. On 11/20/2023 and 12/8/2023 R1 requested incontinence care assistance via call light system. Staff checked on the resident, but stated they would be back to change R1's diaper and never did. On 12/8/23, an attempt was made to communicate R1's needs/staff neglect to staff (S2), but staff stated "I can't talk right now".
Resident (R1) was interviewed and stated that staff allege that the resident refuses to be changed, but that is not the case. The resident stated that sometimes staff came in to the room to change the diaper, while the resident was in the middle of a bowel movement. Therefore, R1 often asked staff to come back in a short while once they are done with their bowel movement, but staff failed to return in a timely manner. Resident (R1) stated that staff "seem to come in to check on me every 3 hours or so", and feels staff are neglectful in meeting incontinence needs. Third party providers have found R1 with dirty diapers. Photographs were obtained. A total of 7 residents were interviewed; none reported issues with incontinence care.
A total of seven (7) staff were interviewed. Staff stated that R1 requires a 2-3 person assist when Hoyer lift is used because the resident is heavy. According to staff, R1 can only rotate themselves to the left side, but is distrustful of staff when repositioning during incontinence diaper changes. Staff stated that R1 gets anxious and is afraid staff will drop the resident when using the Hoyer lift. All caregiver staff interviewed stated that R1 sometimes refused to be changed or rotated, and they did not know if the resident had feces or was wet. According to caregiver staff, they have been instructed to change the resident only when there is a bowel movement, since the resident urinates on a urinal. Staff acknowledged that they have observed urine spilled on the floor and feces on chux pads. According to Administration staff interviews, staff are to report when a resident refuses incontinence care. However, facility was not able to provide documentation (Personal Continence Log) of R1's incontinence care refusal. In addition, staff confirmed that Hoyer lift in R1's room has broken down several times. Third party provider photographs were obtained. On 12/19/23, LPA smelled urine upon entering R1's room, and observed urine on the floor next to the urinal container. There is sufficient evidence to prove the allegation.
See next page. |
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32 | Allegation: Staff do not assist resident with grooming. It is alleged that resident (R1's) grooming needs have been neglected since approximately May 2023, when the resident's condition change to bed-bound. Tooth brushing is only done when the toothbrush is brought to the resident. In addition, R1 has not had a haircut since approximately April 2023, and staff have not offered R1 escort assistance to the facility's beauty salon. According to staff interviews, the cosmetologist is at the facility every Tuesday and residents set up appointments. Staff can ask for special circumstance i.e., haircut in resident's bed. However, staff did not set up a special circumstance haircut appointment, nor did they offer transport to the beauty salon. Staff stated that grooming is supposed to be done in the mornings, which includes hair brushing, cleaning of face with warm washcloth, electronic shaving, and provide tooth brushing assistance. Resident (R1) stated that staff have neglected their grooming needs, and would like to have better grooming. Staff acknowledged that grooming needs of the resident have been neglected. LPA looked at R1's Admission Record picture. The photograph depicts R1 with short hair and good grooming. On 12/19/23, LPA observed R1's hair tangled and unbrushed. The brush was observed next to the television, inaccessible to bed-bound resident. Pictures were taken of R1's face and hair.
Allegation: Staff do not provide resident with clean linen. It was reported that resident (R1's) bed linens are not being changed as required. It is alleged that R1's bed linens were always dirty when third party providers visited the resident. Sheets were often found with feces, blood, and food crumbs. Resident (R1) stated that bed linens are changed by staff when they get "dirty enough", and staff were only changing the disposable under-bed pads as needed. Staff stated that bed linens are changed every week and/or as needed. Families provide linens and most residents have an extra set of sheets. Two (2) out of the seven (7) staff acknowledged seeing dirty sheets, but stated they always change the sheets. However, based on photographs obtained the findings indicate that R1's bed linens are not being changed per facility protocol. On 12/19/2023, LPA did observe bed sheets stained with urine and food.
See next page. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
01/25/2024
Section Cited
CCR
87464(f)(4) | 1
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7 | Basic Services. Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports. | 1
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7 | Executive Director agreed to re-assess all bed-bound and residents receiving incontinence care, and update their care plans. Submit proof of staff training, staff signature logs, and a written plan that addresses Hoyer lift issues.
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14 | Based on record review and interviews conducted resident (R1) required bowel incontinence care since May 2023, due to change in condition to bed-bound. R1 has been left lying in feces and urine and was not provided incontinence care as indicated in care plans. This poses a potential health and safety risk to residents in care. | 8
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14 | In addition, facility shall review all resident records to ensure Care Plans have been updated.
NOTE: R1 moved out on 12/21/23. |
Type B
01/25/2024
Section Cited
CCR
87101(c)(3)(A) | 1
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7 | Definitions. "Care and Supervision" means those activities which if provided shall require the facility to be licensed... "Care and Supervision" shall include, but not be limited to, any one or more of the following activities provided by a person or facility to meet the needs of the residents: | 1
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7 | Executive Director agreed to submit a written plan plan that addresses care responsibilities/protocols for residents with declining/change in health conditions, and grooming responsibilties.
NOTE: R1 moved out on 12/21/23.
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14 | (A) Assistance in dressing, grooming, bathing and other personal hygiene; This requirement was not met evidenced by:
Per record review & photographs, caregiver staff failed to provide grooming assistance as indicated in care plans, which poses a potential health, safety or personal rights risk to persons in care. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
01/25/2024
Section Cited
CCR
87468.1(a)(2) | 1
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7 | Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met evidenced by: | 1
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7 | Executive Director shall ensure all resident's are accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet their needs.
Submit a written plan and proof of staff training. |
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14 | Based on photograph evidence and observations made on 12/19/23, R1's bed sheets/linens were observed to be dirty with urine, feces, and food; which posed a potential health, safety or personal rights risk to persons in care. | 8
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Type B
01/25/2024
Section Cited
CCR
87307(d)(3)(B) | 1
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7 | Personal Accommodations and Services.The following space and safety provisions shall apply.... All persons shall be protected against hazards within the facility through provision of the following:(B) Information and instruction regarding life protection and other appropriate subjects. | 1
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7 | Executive Director shall ensure all staff follow care and supervision protocols. Submit a written plan and proof of staff training. |
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14 | Based on photographs and observations made the findings indicate that staff failed to remove hazardous items i.e. toothpicks, plastic knives from R1's bed, which can cause skin tears. This posed a potential health, safety or personal rights risk to persons in care. | 8
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32 | Allegation: Staff did not ensure that a hazardous item was made inaccessible to resident. It is alleged that toothpicks and plastic knifes have been observed underneath R1's body, which pose a safety hazard because a wound may develop, could become infected or could result in sepsis. Resident (R1) stated that they have plastic wear by the bedside because staff sometimes forget to bring plastic wear with meals, and does drop toothpicks and knives on the bed. Staff interviews revealed that plastic forks, plastic spoons, food, and toothpicks have been found in the bed during incontinence care, and staff are instructed to check/remove hazardous items found in residents' beds. On 12/19/2023, LPA observed a toothpick next to the resident's right hand, and plastic fork on the floor. The findings indicate that staff need to be more cognizant of what is considered hazardous, which may cause skin tears. It is the responsibility of facility staff to ensure all residents are safe, and facility protocols are followed.
Based on interviews conducted, document review, and photographs obtained, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22. See LIC 9099D.
An exit interview was conducted with Executive Sanjay Vaid. A copy of the report and appeal rights were issued.
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