Allegation: “Facility left resident on floor all night:”

It was alleged that Resident #1 (R1) had fallen on the floor around 10:30PM and facility staff did not assist R1 in getting up off the floor until the following morning. Documents reviewed for R1 revealed that R1 was obese, had 1 (one) leg amputated below the knee, and R1 required assistance with activities of daily living (ADLs) such as help transferring in and out of bed and dressing. Interviews revealed that R1 “was a big guy,” approximately 6’8” tall, obese, and did require a 2-person physical assist. While it is unclear whether R1 had a Hoyer lift at the time of the alleged fall, R1 reportedly did have a Hoyer lift at some point in the facility. Based on R1’s stature, interview revealed that R1 would have required a 2-person assist even with the use of the Hoyer lift. Staff interviewed indicated at the time of the allegation, the facility was short staffed and during the overnight (NOC) shift, the facility regularly had 1 (one) care staff and 1 (one) medication technician working. It was reported that at times, there was only 1 (one) staff in total for the entire facility. Staff interviewed at the time of the complaint indicated that yes, they had found R1 on the ground and they had heard that multiple residents were left on the ground a long time, including R1. Both R1’s family member and staff interviewed stated R1 had been left on the ground overnight. Additional residents interviewed at the time stated they were left on the ground for extended periods of time, ranging from 45 minutes to all night. Administrator confirmed R1 was left on the floor all night and an incident report was sent to the Riverside Regional Office related to the incident. Based on interview and record review, the allegation “facility left resident on floor all night” is deemed SUBSTANTIATED at this time.

Allegation: “Resident does not get fed at times:”

LPA conducted resident and staff interviews and reviewed additional interviews conducted around the time the complaint was received. Interview with staff revealed that yes, there are residents who have missed meals. While most residents go to the dining room during mealtimes, there are some who receive their food in their room. Kitchen staff were assigned to set up room trays and deliver them to the residents, as the residents had requested. At the time, the facility maintained a list of residents that get a room tray. Staff and residents interviewed indicated that staffing was inadequate at the time of the complaint allegation and due to staffing, residents had missed meals. Administrator indicated that he was helping pass out meals and, on that day, R1 had received their meal. Administrator indicated although there was no checklist in place to

Allegation: “Resident not bathed according to schedule:”

Documents reviewed for R1 revealed that R1 did require assistance with bathing and dressing. R1’s family member informed LPA that when R1 had resided in a room with a bathroom/shower inside the room that R1 was provided shower assistance regularly. However, when R1 was moved to another smaller room with no bathroom attached that the showers were not provided. According to staff interviewed, the care staff are responsible for showering residents who are not receiving hospice services twice a week. The facility does have a shower schedule and R1 was on the shower schedule at night. However, interview with staff revealed that R1 had not been receiving showers in the night, so day staff had provided R1’s last shower 2 (two) weeks prior to the initial complaint visit. Administrator confirmed via interview that there has been a delay in some residents getting a shower and that there were a lot of residents affected. Other residents interviewed at the time of the complaint allegation indicated they had not received showers in 1-2 weeks, but were supposed to receive a shower twice a week. Based on interview, the allegation “resident not bathed according to schedule” is deemed SUBSTANTIATED at this time.

Allegation: “Resident is left in dirty diaper:”

Record review revealed that R1 does require staff assistance to meet R1’s toileting needs. Staff interviews revealed that they are supposed to do 2-hour checks for the residents to ensure they are clean and dry. Administrator stated that the AM staff aren’t doing the 2-hour checks because they are busy helping residents. The Administrator did have a log to track R1’s incontinence needs, but staff stopped using the log. Staff interviewed indicated that R1 needed a larger incontinence brief than most residents, and the facility regularly did not have the right size brief available for R1’s use. Additionally, R1 was a 2-person assist for transfers and turning, as required when changing a R1’s incontinence brief. Interview revealed that the facility only had 1 (one) or 2 (two) caregivers present working during most shifts and that some staff refused to assist R1 with their incontinence needs. Other residents interviewed confirmed that at the time of the complaint allegation, they were left regularly in wet or soiled briefs all day. Documents reviewed indicated

Allegation: “Staff failed to assist resident with medical appointment:”

The complaint alleges that R1 had early morning medical appointments and that staff did not wake up R1 and assist R1 in getting ready timely, which caused R1 to miss their scheduled appointments. Interview revealed that the receptionist keeps a list of people who have appointments on a certain day. Administrator confirmed that one resident did miss an appointment but is unsure if it was R1 who missed the appointment or if it was another resident. On the date the complaint refers to, it was confirmed by the Administrator that there was only one staff present, a medication technician, at the facility from 06:00AM until 10:00AM, when a second staff arrived. Staff interviews revealed that medication technicians can assist residents with ADL needs as time permits, however, medication assistance and compliance is their primary focus not ADL care. Staff interviewed indicated that R1 should have received a shower the night before the appointment, to ensure R1 could be assisted timely when an early morning appointment was scheduled, however R1 was not offered showers at night. Interview with R1’s family member revealed that the medication technician working the morning of the missed appointment was aware of the appointment, but no one went to R1’s room to wake them. Other residents interviewed indicated they had similar problems with requesting an early wake up time, as there were not enough staff present in the building to assist the residents in the morning. Based on interview, there is sufficient evidence to support the allegation, therefore the allegation “staff failed to assist resident with medical appointment” is deemed SUBSTANTIATED at this time.

Pursuant to Title 22, CA Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 9099-D).

Due to the facility closure on April 15, 2024, a copy of this report and appeals rights (LIC 9058 1/16) will be sent via email to Adam Zenou at Adam@skilledmanagementco.com and another certified copy via USPS to Mr. Zenou’s at the his last known address. Former licensee/delegate should review, sign the report with a wet signature, and email the report back to CCLASCOWoodlandHillRO@dss.ca.gov or mail the report directly back to the LPA listed on the report at 21731 Ventura Blvd., Suite 250, Woodland Hills CA 91364.

It was alleged that unqualified staff are passing out medications, but no additional information was provided related to which staff and if additional residents were affected, other than Resident #1 (R1). LPA interviewed staff related to the allegation. Staff indicated that only qualified trained medication technicians provide medication assistance to the residents and that there are medication technicians scheduled each shift with coverage 24 hours a day at the facility. LPA reviewed training records for 1 (one) available staff person and confirmed this individual did have the required medication training and was employed as a medication technician at the time of the complaint. Administrator interview revealed that all staff have had the medication training and examination prior to passing out medications to residents. At the time of the subsequent visit, LPA observed qualified staff attending to residents’ medication needs. Based on interview and record review, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation “staff are not qualified to hand out medications” is deemed UNSUBSTANTIATED at this time.

No citations issued related to this allegation. Due to the facility closure on April 15, 2024, a copy of this report will be sent via email to Adam Zenou at Adam@skilledmanagementco.com and another certified copy vis USPS to Mr. Zenou’s at the his last known address. Former licensee/delegate should review, sign the report with a wet signature, and email the report back to CCLASCOWoodlandHillRO@dss.ca.gov or mail the report directly back to the LPA listed on the report at 21731 Ventura Blvd., Suite 250, Woodland Hills CA 91364.