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13 | On 10/17/24, Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced subsequent visit to investigate the allegation listed above. Upon arrival LPA met with Staff #1 (S1) and explained the reason for the visit. S1 contacted the Administrator (Helen Abeshyan) and LPA explained the purpose of the visit.
During the last visit, LPA toured the facility. LPA requested a copy of the resident roster, Resident #1 (R1), Needs and Services Plan, R1 Admission Agreement, R1 Medication Administration Record (MAR) for September and October, R1 Physician’s Report, Care Giver Notes, R1 Kaiser Permanente Mail Order Pharmacy, Photos of R1 and Staff Roster via email. LPA interviewed: Administrator and one (1) staff who shall be referred to as S1. LPA interviewed four (4) residents referred to as R1 through R4. Due to Resident #4 through Resident #6 diagnosis LPA could not conduct or use their interviews. LPA also interviewed three (3) Witnesses who shall be referred to as W1 through W#3.
Before today's visit, LPA interviewed a 4th witness, who shall be referred to as W4. LPA also received photos of resident #1. Report continued on 9099C
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| Substantiated | Estimated Days of Completion: |
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32 | The investigation reveals the following: " Resident sustained excoriation of the skin due to lack of care from staff”. It is alleged the R1 is in prolonged moisture. During the visit, the Administrator denied the allegation stating that R1 is changed as needed and refuses assistance from care staff. LPA asked the Administrator if they placed double briefs on R1, and the Administrator confirmed with S1 that they did not. 1 out of 3 residents stated they receive assistance to the restroom as needed. 1 out of 3 residents confirmed staff leave them sitting in urine. LPA Baptiste received photo proof of the resident's distended brief and confirmed via photos the resident was wearing double briefs. According to W4, R1’s excoriation was improving, but due to the excess moisture, R1’s excoriation worsened, which prompted W4's home health agency to be worried about the progression of R1 excoriation. LPA received photos of the excoriations and observed the worsening of R1's excoriations.
The investigation reveals the following: " Staff is not meeting resident's toileting needs”. It is alleged that R1 sits in feces and urine. During the visit, the Administrator denied the allegation stating R1 is a difficult resident and has contacted the physician. 1 out of 3 residents confirmed they receive assistance to the restroom as needed. 1 out of 3 residents confirmed staff left them sitting in urine and feces. The resident further stated at night staff is not around to change them, but in the daytime, they are changed. LPA Baptiste received photo proof of the resident's distended brief and confirmed via photos the resident had dried feces on there hands.
The investigation reveals the following: " Staff is not meeting resident's hygiene needs”. It is alleged that R1 was eating with dried feces on their hands. During the visit, the Administrator denied the allegation. 1 out of 3 residents stated they receive assistance to the restroom as needed. 1 out of 3 residents confirmed there were three (3) times feces was on their hands. The home health agency confirmed the allegation. LPA Baptiste received photo proof of dried feces covered on the resident’s hands.
Based on LPA observation, interviews and file review, the preponderance of evidence standard has been met, therefore the above allegations is found to be SUBSTANTIATED. California Code of Regulation, Title 22 are being cited on the attached LIC9099D.
Exit Interview Conducted with Administrator via phone/ Appeal Rights Provided / A Copy of the Report Issued. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
10/24/2024
Section Cited
CCR
87625(b)(7) | 1
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7 | (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (7) Ensuring that the condition of the skin exposed to urine and stool is evaluated regularly to ensure that skin breakdown is not occurring. | 1
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7 | Licensee will ensure that resident is changed as needed to help improve the excoriation. Training will be conducted with staff on how to deal with a difficult resident and how often the briefs should be changed. Proof of the training will
be email to CCLD by plan of correction due date. |
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14 | This requirement was not met as evidence by:
Due to interviews and photo proof. LPA observed skin break down on Resident #1 with a full distended brief, which poses a potential health, safety, or personal rights risks to persons in care. | 8
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Type B
10/24/2024
Section Cited
CCR
87625(b)(3) | 1
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7 | (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. | 1
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7 | Licensee will ensure that resident is changed as needed, including nights. A Care plan will be established in with a log of residents brief changes. Proof of the training will be email to CCLD by plan of correction due date. |
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14 | This requirement was not met as evidence by:
Due to interviews and photo proof. LPA observed skin break down on Resident #1 with a full distended brief, 2 briefs at once and photos of dried feces on the residents hands , which poses a potential health, safety, or personal rights risks to persons in care. | 8
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