Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of NEGLECT/LACK OF SUPERVISION: Resident sustained a fractured hip while in care is found to be UNSUBSTANTIATED.

Evaluation Report continues LIC9099-C

Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of NEGLECT/LACK OF SUPERVISION: Resident sustained multiple falls while in care is found to be UNSUBSTANTIATED.

Regarding Allegation #3: this investigation alleges that Resident #1 was being improperly restrained from getting out of their wheelchair by facility staff. Resident #1 is wheelchair bound and could not ambulate on their own and had an ongoing behavior of attempting to get out of bed or the wheelchair. The increased supervision (by facility staff) provided an appropriate level of supervision – despite the behavior demonstrated by Resident #1. Interviews conducted with facility staff (A1, S1-S4) and residents (R2-R9) corroborated that a resident was not observed restrained improperly in a wheelchair. A review of Resident #1’s “Physician Report” (dated 10/16/20) and “Appraisal/Needs and Services Plan” (dated 03/03/21) and “Requirements for Private Duty Attendants Providing Services at the Community” were on file. A review of Resident #1’s records did not document that the resident had an “Exception Waiver” for postural support (restraint/belt) on file. Administrator Mariano is aware that if one is needed for a resident, Administrator will notify Community Care Licensing (CCL) and have a doctor's order on file for the resident prescribing the support (pursuant to Section 87608 Postural Supports). Interviews conducted of facility staff (A1, S1-S4) corroborated that the staff are very attentive to the residents’ needs and provide a good level of care for these residents. Interviews conducted of witnesses (W1 & W2) were very pleased with the level of care and supervision that Resident #1 was receiving at the facility.

Evaluation Report continues LIC9099-C

Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of PERSONAL RIGHTS: Facility staff improperly restrained resident is found to be UNSUBSTANTIATED.

Regarding Allegation #4: this investigation alleges that facility did not safeguard Resident #1’s clothes; and, another resident was observed wearing Resident #1’s clothing during Reporting Party’s visit to the facility. In addition, Resident #1 was wearing a different pair of prescription eyeglasses that did not belong to them. On or about 08/10/21, Resident #1 developed a behavior of removing their clothing from their person as witnessed by a hospice provider visit; and, it was reported to the resident’s Primary Care Physician and Conservator. Interviews conducted of facility staff corroborated that the staff do safeguard residents personal belongings and were unaware of a resident missing personal belongings. An interview was not conducted with Resident #1 due to the resident’s cognitive impairment. Residents (R2-R9) were interviewed and did not express concerns with facility staff not safeguarding their personal belongings. Administrator Mariano stated that facility staff would follow protocol if a resident reported missing personal belongings from their room. A review of Resident #1’s “Safeguard for Property/Valuables” was on file. Resident #1’s Conservator and Responsible Person were very pleased with the level of care and supervision that Resident #1 was receiving at the facility.

Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of PERSONAL RIGHTS: Facility staff did not safeguard resident's personal belongings is found to be UNSUBSTANTIATED.

Evaluation Report continues LIC9099-C

Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of PERSONAL RIGHTS: Facility staff did not allow resident to leave the facility with family is found to be UNSUBSTANTIATED.

Regarding Allegation #6: this investigation alleges that a family member (daughter) visiting with Resident #1 observed a caregiver improperly lifting and placing the resident to use the restroom. Interviews revealed that facility staff have received hands on and classroom training, Staff 1-3 (S1-S3) interviewed stated staff are trained and are receiving ongoing training. A review of facility staff training records documents the topic “Proper Body Mechanics” including “hands-on” Transfer Training conducted by a home health physical therapist. Interviews conducted of facility staff (A1, S1-S4) corroborated that they are trained to transfer residents and receive ongoing training. Interviews conducted of witnesses (W1 & W2) corroborated that they have observed facility staff to be competent, trained, and providing the necessary care and supervision to meet the needs of Resident #1. An interview was not conducted with Resident #1 due to the resident’s cognitive impairment. Interviews conducted of residents (R2-R9) corroborated that facility staff are trained to assist residents with their daily needs and provide the care and supervision.

Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of PERSONAL RIGHTS: Facility staff are not properly assisting resident with transfers is found to be UNSUBSTANTIATED.

Evaluation Report continues LIC9099-C

An exit interview has been conducted and a copy of the Complaint Report was provided to Care Coordinator Fabiola Marciano.

Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of NEGLECT/LACK OF SUPERVISION: Facility resident threatens visitor is found to be UNSUBSTANTIATED.

Regarding Allegation #8: this investigation alleges that facility staff are not regularly brushing Resident #1’s teeth and not assisting the resident with changing their clothing regularly. A review of Resident #1’s “Appraisal/Needs and Services Plan” (dated 03/03/21) documents that facility staff assists the resident with all toileting needs and bathing needs. A review of Resident #1’s “Physician Report” (dated 10/16/20) documents that facility staff assist the resident with dressing/grooming. Interviews conducted of facility staff (A1, S1-S4) corroborated that the staff are very attentive to Resident #1s’ needs and provide a good level of care. Interviews conducted of witnesses (W1 & W2) corroborated that they were very pleased with the level of care and supervision that Resident #1 was receiving at the facility. An interview was not conducted with Resident #1 due to the resident’s cognitive impairment. Interviews conducted of residents (R2-R9) corroborated that they are very happy living at the facility and that facility staff are attentive in providing the care and supervision to meet their activity of daily living needs.

Evaluation Report continues LIC9099-C