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32 | R1’s ambulatory status declined, and R1 became increasingly bed bound. R1 was placed on hospice services on August 26th, 2022. The facility’s Needs and Services plan noted R1 required total assist. A Resident Assessment conducted on February 16th, 2023, revealed R1 required assistance with toileting and incontinence checks and changes. R1 required a two person assist for transfers, ambulating, and escorting.
An external source revealed hospice visited R1, and trained caregivers on repositioning, wound care and keeping R1 clean and dry. This was documented on the Hospice care notes obtained from the facility. Interviewed caregivers and medication technicians stated they would reposition R1 every two hours, changed R1’s briefs, kept R1 dry, and would change out soiled bandages per hospice’s and nurses’ directions. These interviews noted hospice had not advised staff of any severe discrepancies in R1’s care, nor provided training.
Although facility staff stated they kept R1 dry, repositioned R1, and that hospice did not communicate the severity of R1’s wounds, numerous notes from hospice noted R1 was found with soiled briefs and linens on multiple occasions. The hospice notes also revealed hospice communicated the importance of repositioning R1, and that hospice provided training for staff on multiple visits.
Interviews with the facility’s Executive Director and Resident Care Coordinator confirmed the facility did not obtain a hospice care plan for R1, and instead followed the facility’s care plan for R1. The facility’s Need and Service Plan for R1 noted staff would follow orders within staff’s scope of practice. This plan did not note the need for repositioning.
Interviews confirmed R1’s wound healing did not progress until after a care conference was held with facility management on February 23rd, 2023, and after the complaint was submitted to the Department.
Based on the information provided during the investigation, the allegation was substantiated.
It was alleged staff did not meet R1's incontinence needs. It was reported to the Department R1 was found to be soiled on multiple occasions. Hospice notes revealed hospice staff found R1 with soiled briefs and facility staff was trained and advised of the importance of keeping R1 dry. Interviewed staff reported providing R1 incontinence care and keeping R1 dry. Interviews with internal and external sources reported concerns with how long it took staff to respond to calls for assistance with incontinence care.
(See additional LIC 9099-C for continuation of report.) |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
04/08/2025
Section Cited
CCR
87468.2(a)(8) | 1
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7 | 87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
(8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.
This requirement was not met as evidence by: | 1
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7 | Administrator agreed to have an outside agency provide in service training to all staff regarding repositioning, monitoring and docuementing wounds. Administrator agreed to submit proof of training to the LPA, by May 8th, 2025. |
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14 | Based on interviews and review of records, the licensee did not ensure R1 was free of neglect resulting in pressure injuries, which posed a potential health, safety and personal rights risk to 1 (R1) of 71 residents in care.
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Type B
04/08/2025
Section Cited
CCR
87625(b)(3) | 1
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7 | 87625 Managed Incontinence (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. This requirement was not met as evidenced by: | 1
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7 | Administrator agreed to review policies and procedures regarding incontinece care with all staff. Administrator agreed to submit proof of this training to the LPA, by May 8th, 2025. |
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14 | Based on review of records, and interviews, the licensee did not ensure incontinent residetns were kept clean and dry, which posed a potential health, safety, and personal rights risk to 3 residents in care. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
04/08/2025
Section Cited
CCR
87307(a)(3)(C) | 1
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7 | 87307 Personal Accommodations and Services (a) (3)(C)Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times...
This requirement was not met as evidenced by:
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7 | Administrator agreed to discuss the importance of having linens on each residents's bed at all times with housekeeping and care staff. Adminstrator will provide documentation to the LPA by May 8th, 2025. |
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14 | Based on review of records and interviews, the licensee did not ensure residents had clean linens at all times, which posed a pontential health, safety, and personal rights risk to residents in care. | 8
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