It was alleged that the facility contacted the incorrect parties to retrieve R1’s personal possessions when R1 passed away. Information obtained from the complainant supported claims that R1’s belongings were picked up from a friend of R1. A review of facility records indicated that R1 did not have a Power of Attorney (POA) on file, and per the Identification and Emergency Information sheet on file for R1, R1 indicated three (3) ‘friends’ as persons to contact in the case of an emergency. The LPA also reviewed the Hospice Face Sheet, and there wasn’t a ‘next of kin’, authorized representative, nor emergency contact listed. Interviews were conducted with the persons listed on R1’s Identification and Emergency Information sheet on 12/30/2022 at 11:34 a.m., 2:55 p.m., and 3:10 p.m., and all parties denied claims that they were contacted regarding R1’s passing nor did the facility staff contact them to pick up R1’s belongings.

An interview conducted with R1’s family member on 12/2/2022 at 1:23 p.m. supported claims that despite all efforts, R1 was their own responsible party and noted that R1 denied assistance from their family. Staff interviews supported claims that R1 had a lot of ‘friends’ and commented that R1 had a number of friends whom visited the facility. Staff claimed were not clear on the relationship that R1 sustained with their family member(s) and commented that R1 had a sibling that they ‘did not talk about’. Upon R1’s passing, staff felt it was best to contact someone whom had visited R1 frequently. After further discussion regarding R1’s next of kin, staff alleged they did not have the contact information of R1’s family on file. A follow up interview with the Administrator on 12/30/2022 at 3:55 p.m. revealed that they had asked R1 whom they should contact in the case of an emergency, and the Administrator listed a name of someone who was not listed on R1’s Identification and Emergency Contact sheet. The Administrator alleged that they had documented this in a ‘separate book’ but was unable to state why they did not contact the person(s) listed on R1’s Identification and Emergency Contact sheet.

Based of the information obtained from interviews and record review, there is sufficient evidence to support the claim that the facility staff did not ensure safe keeping of resident's personal possessions. Staff failed to contact R1’s emergency contact(s) to collect R1’s personal possessions. This allegation is deemed Substantiated at this time.

Regarding the allegation: Facility did not have sufficient staff to meet the residents' needs.

It was alleged that the facility did not have adequate staffing, as presumed due to the claim that R2 suffered a fall and was left on the floor for an extended period of time. However, the availability of evidence from interviews and records obtained were unable to corroborate claims that R2 was left on the floor for an extended period of time. To investigate, the LPA(s) conducted interviews and reviewed records to identify the needs of the residents in the facility.

Regarding R1, concerns were raised regarding the care R1 received in the facility. It was alleged that R1 suffered a toe infection for ‘over a year’ that presumably went untreated. A review of hospice records and an interview with a hospice nurse assigned to R1’s care supported claims that R1 was observed to have a toenail infection on the right toe on 10/21/2020 as a result of an ingrown toenail. As a result, would care for the right toe was added to R1’s hospice care plan and the treatment of the infection was monitored by the nurse from the hospice agency during each visit. Records review indicated a wound care specialist closely monitored the wound on R1’s toe, and records indicated that the last visit on record was 9/21/2021 for the chief complaint of ingrowing thick discolored toenails on both feet and a specific ingrown nail on R1’s right toe. Regarding R1’s overall care, R1 was regularly seen by a hospice nurse and home health aide on a weekly basis. Interviews with the hospice nurse whom provided care to R1 mentioned that staff were ‘on top’ of R1’s care and denied claims that R1 ever appeared unkempt. In addition, it was communicated that facility staff kept R1’s skin dry and intact. As R1 was at risk for skin breakdown due to limited mobility and incontinence, the hospice nurse confirmed that R1 did not sustain any pressure injuries while residing at this facility.

Based on interviews and record review, there is insufficient evidence to support claims that R1’s needs were not met. Yet, although the facility may have had an adequate number of staff in the facility, based on evidence obtained from interviews, it demonstrated that staff failed to adequately meet the needs of all of the residents in this facility. Based on interviews, the preponderance of evidence standard has been met, therefore, the above allegation is deemed Substantiated at this time

Regarding the allegation: Facility staff did not speak a language that the residents understood resulting in a language barrier.

It was alleged that residents were unable to communicate with staff due to a language barrier. It was alleged that R1 had to sometimes utilize photos in communicating their needs to staff. A review of social media posts written by R1 reflected that R1 oftentimes talked about the language concerns with some of the staff at the facility but commented that their needs were otherwise met. Staff explained that they would utilize Google Translate or would ask another staff for assistance if need be to meet the needs of the residents. During the visit conducted on 1/14/2022 by LPA Salia Walker, two (2) out of six (6) residents indicated that they were unable to communicate their care needs to one of the staff (Staff #1). Additional resident interviews were conducted on 12/20/2022 and one (1) out of three (3) residents commented that they were unable to communicate with S1, which resulted in unmet needs. An interview conducted with R2’s responsible party supported claims that they were unable to communicate with S1 and noted that R2 also was unable to communicate their needs to R2, which resulted in misunderstandings.

Pursuant to Title 22 of the California Code of Regulations and Health and Safety Code, the following deficiencies were cited (refer to LIC 9099-D). Failure to correct deficiencies may result in civil penalties. Exit interview conducted with Administrator Asmik Nadrian. A copy of the report, and appeal rights were issued.

Regarding the allegation: Facility did not seek resident timely emergency medical services resulting in resident's untimely death.

It was alleged that R1 had trouble breathing, which would have been cause for the facility to seek emergency medical services. A review of medical notes indicated that R1 was admitted to this facility with hospice services on 3/18/2020, with the admitting diagnosis of chronic obstructive pulmonary disease. According to Mayo Clinic, chronic obstructive pulmonary disease, commonly known as COPD, is a chronic inflammatory lung disease that causes obstructed airflow from the lungs. Other co-morbidities listed for R1 included shortness of breath, wheezing and generalized body weakness. R1 also had an order to receive oxygen at a flow rate of two liters per minute in order to facilitate breathing and shortness of breath on an as needed basis. As a result, hospice was monitoring R1’s condition during every visit.

A review of hospice nursing notes indicated that throughout the duration of R1 residing at this facility, R1 often experienced shortness of breath with minimum to moderate exertion, and staff supported claims that R1 used oxygen at all times. This observation was regularly documented on the hospice notes reviewed from 3/18/2020 – 11/24/2021. Interviews with staff and the hospice nurse whom provided care to R1 denied claims that prior to R1’s passing that R1 experienced a notable change of condition. Interviews confirmed that R1 had experienced issues with their oxygen tank; however, interviews and documentation supported claims that R1’s oxygen tank was repaired at different intervals. Documentation supported claims that R1’s oxygen tank was replaced approximately three weeks prior to R1’s passing. Staff interviews conducted on 12/22/2021 claimed that on 11/26/2021, R1 complained of troubled breathing and noted that the oxygen machine was not working. Staff claimed that they reported this occurrence to the hospice nurse, whom then placed an order for a new oxygen tank and noted that the new tank arrived ‘within 45 minutes’.

Acquaintances whom regularly communicated with R1 supported claims that prior to R1 passing, persons received an email from R1 written on 11/23/2021 that R1 had experienced ‘minimal oxygen’ for five (5) days prior. Yet additional context was not provided as to what determined ‘minimal oxygen’ for R1. In addition, insufficient evidence was obtained from staff and hospice per interviews, as staff and hospice denied claims that they were aware of any exacerbated breathing issues from R1 outside of having R1’s oxygen tank replaced prior to R1’s passing. Staff claimed that if there ever were challenges with R1’s oxygen tank that they immediately contacted the hospice agency. Lastly, persons whom spoke with R1 the night prior to R1 passing claimed that R1 ‘did not sound right’, and that R1 allegedly had trouble breathing. Throughout the duration of R1 residing at this facility, R1 had experienced trouble breathing and shortness of breath due to their condition. As R1 was on hospice, staff were instructed to call the hospice agency if an emergency was observed that was related to the condition in which the resident is admitted to hospice. As R1’s admitting diagnosis was COPD and staff and hospice were aware of R1’s breathing issues, staff claim that R1 did not exhibit symptoms outside of their normal baseline. Staff denied claims that R1 exhibited symptoms prior to their passing that would lead one to contact emergency services. Hospice stated that they did not receive any emergency calls regarding R1 prior to R1’s passing, and claimed that during their last visit with R1, R1 did not exhibit symptoms that would indicate that R1’s health was failing nor that R1 required emergency services. Per protocol, upon observing R1 the morning of 11/27/2021, staff contacted the hospice agency. Hospice arrived the morning of 11/27/2021 and R1 was pronounced deceased. R1’s cause of death, per the death certificate, was cardiorespiratory failure and COPD.

Based on the information obtained from interviews and record review, there is insufficient evidence to support the claim that the facility did not seek timely emergency medical services for R1, which ultimately led to R1’s passing. Although the allegation may have happened or is valid, there is insufficient evidence to prove the above-mentioned claim at the time the complaint was received. Therefore, the allegation is deemed Unsubstantiated at this time.

It was alleged that R1 had challenges with their oxygen tank, and the facility failed to have it repaired in a timely fashion. A review of medical notes indicated that R1 was admitted to this facility with hospice services on 3/18/2020, with the admitting diagnosis of chronic obstructive pulmonary disease. R1 also had an order to receive oxygen at a flow rate of two liters per minute in order to facilitate breathing and shortness of breath on an as needed basis.

Interviews confirmed that R1 had experienced issues with their oxygen tank; however, interviews and documentation supported claims that R1’s oxygen tank was repaired at different intervals throughout their time at the facility. Documentation supported claims that R1’s oxygen tank was replaced approximately three weeks prior to R1’s passing. Documentation supported claims that R1’s oxygen tank was replaced weeks prior to R1’s passing. Hospice indicated one time in which they were informed by facility staff that R1’s tank appeared inoperable, yet hospice claimed they replaced the tank within an hour. A review of hospice notes indicated that a new nasal canula was ordered for R1 on 4/27/2021 and 10/29/2021, indicating that repairs for the oxygen tank were completed as needed.

Acquaintances whom regularly communicated with R1 supported claims that R1 would regularly communicate updates via email and on social media regarding their progress, including any issues with their oxygen tank. R1 noted on 5/14/2021 that they had challenges with their oxygen tank, but said that the facility provided them with a spare tank until the company delivered a new one. R1 noted on 10/27/2021 that their oxygen tubes were changed on their oxygen tank, which allegedly made it hard to breathe. R1 also claimed that their oxygen meter went below 94%, yet it was typically at 97-99%. However, there is no evidence as to whether this was shared with the facility staff or hospice, or if this concern was addressed. R1 noted that on 11/23/2021, prior to R1 passing, R1 communicated via email that R1 had experienced ‘minimal oxygen’ for five (5) days prior. Yet additional context was not provided as to what determined ‘minimal oxygen’ for R1. In addition, insufficient evidence was obtained from staff and hospice per interviews, as staff and hospice denied claims that they were aware of any exacerbated breathing issues from R1. Staff claimed that if there ever were challenges with R1’s oxygen tank that they immediately contacted hospice.

Throughout the duration of R1 residing at this facility, R1 had experienced trouble breathing and shortness of breath due to their condition.

Regarding the allegation: A resident fell out of bed and laid on the floor for an extended period of time.

It was alleged that a resident (R2) fell on the floor and was left there for an extended period of the time. Per the complainant, the information was relayed from R1 via a social media post. The LPA reviewed the social media posts of R1 and was unable to identify the post in question. Yet, it was alleged although staff observed R2 on the floor, staff allowed R2 to stay on the floor for an extended period. Staff interviews revealed conflicting information as to whether R2 ever fell. Interviews notated that there was a full bedrail on R2’s bed, and records review indicated that an appropriate order was on file for the full bedrail. Information obtained from the complainant alleged that R1 did not hear or observe R2 fall out of bed and suspected that R2 ‘assisted’ themselves onto the ground.

Staff supported claims that R1 had not fallen out of bed during their stay at the facility; however, staff claimed that R2 attempted to get out of bed and had moved their bedrail in order to do so. Staff claimed that they quickly assisted R2 back to bed once it was observed that R2 was on the floor. An interview with R2’s responsible party did not yield sufficient evidence to support claims that R2 had suffered a fall, as it was communicated that R2 suffered from generalized weakness and was believed to lack capacity to transfer themselves out of bed. R2’s responsible party denied knowledge of R2 falling out of their bed. Whereas staff claimed that they had to use a hoyer lift to get R2 back into bed, interviews with R2’s responsible party negated claims that the staff would use a hoyer lift to assist, despite many requests from R2’s responsible party. However, R2’s responsible party was unaware of R2 sustaining a fall, nor was able to validate claims that R2 was on the floor for an extended period of time. Lastly, despite their request for the staff to utilize a hoyer lift to assist with transfers, R2’s responsible party was unable to provide evidence as to whether the staff utilized the lift during the assumed fall.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.