Staff interviews corroborated this allegation, as staff who had observed this issue informed witnessing specific caregivers exhibiting impatience with memory care residents by raising their voices or stating they would not help them. Staff interviews additionally revealed observations of a staff member hitting the hands of a resident during care when the resident was resisting, forcing a resident's hands from a bed rail and moving faster than the resident wanted to go, ignoring their protests. Additional staff observations included a staff member mocking a resident and responding to a resident in a way that escalated the resident's behavior instead of attempting to calm the resident down, a staff member using inappropriate supplies to clean a resident, improper protocols while changing a resident that did not maintain their dignity, and a group of staff not being respectful of a resident's change in condition. During interviews staff were asked if the situations were elevated, which some staff affirmed that they had notified management when the incidents occurred. Staff additionally mentioned that the incidents occurred during times where no management, families, or agency visitors were present. One incident was noted regarding an accusation against a staff member that had been previously investigated by the Department through case management and found to be unsubstantiated.

Facility records were not found to show that the incidents named by staff were documented in staff files or that the staff were reprimanded for the incidents named.

Outside sources were interviewed regarding the allegation. No outside sources had observed dignity issues by staff toward residents.

Regarding the allegation, "Staff did not respond to residents' call buttons in a timely manner", it was alleged that residents experienced long wait times for staff assistance when they pushed their pendants. Staff interviews provided differing expectations of facility policy wait times, ranging from 7 to 20 minutes. Five (5) staff stated that the response times were reasonable and/or between 7-15 minutes. Five (5) staff stated that the response times were too long, observing wait times in excess of 30, 40, 60, 90 minutes, and three (3) hours. Staff stated that the that the response delays occurred on certain floors or during certain times of day.

Staff informed that some of the reasons for the wait times had to do with the pendant technology, the phones not working to know that a resident had paged, or not having a magnet to clear the phone. Other staff interviews revealed that some residents over-utilized their pendants, did not understand how to use them/pushed them in error, misplaced them, or would not allow staff to clear it. Staff who informed long wait times informed that there was no reasonable explanation for the delayed responses they witnessed, and that the staff members observed were on their personal phone instead of attending resident calls. Staff stated that while not every call was legitimately missed, the overall response time was too long and that management was aware. Staff additionally stated that the response times and assistance from management has recently improved with the new Memory Care Director.

Review of facility pendant logs for the month of May 2025 revealed that a pattern of extended wait times did exist, corroborating the allegation and staff interviews. Excluding outliers, the pendant log showed that approximately 126 (one hundred twenty six) calls had response times greater than 20 (twenty) minutes.

Outside source interviews were mixed regarding the allegation, as some sources informed that their respective residents were not cognizant to utilize their pendant, other sources stated that their residents did express to them that the response times were slow, and further sources informed not being concerned about response times or not having observed the response times.

Resident interviews confirmed the wait times, as resident stated that they had waited 20 minutes or greater, or pushed their pendant and no staff responded to their call.

Regarding the allegation, "Staff did not provide adequate supervision to resident(s)", it was alleged that staff were observed sleeping on shift and there were times when residents were not being supervised. Staff interviews corroborated this allegation, as nine (9) staff informed of being aware and/or directly observing staff sleeping on shift or being on their phones in lieu of assisting residents. During interviews, clarification was made to confirm that these instances negatively affected resident supervision, or that there were no staff actively supervising the residents, which was affirmed. Staff informed that an internal policy existed restricting staff from being on their phones while working the care floors, however not all staff adhered to this rule. Staff offered specific observations such as entering a care floor and observing all caregivers sitting in the corner on their phones, a caregiver on their phone with earbuds in both ears while not on break, a caregiver falsely stating where they were on two occasions while 2-person assist residents were waiting for assistance, and staff sleeping on shift while not on break. (Continued on LIC9099 p.4)

Interview information showed that a pattern existed on certain resident floors during certain times of the day.

Outside sources were interviewed regarding the allegation. No outside sources had observed inadequate supervision by staff, however, the outside sources confirmed during interview that they did not visit their respective residents during the timeframe in question.

Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violations occurred and are therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Executive Director Rob Daynes, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Staff interviews did not corroborate this allegation, as staff consistently stated that R1's medical conditions made it very painful for them to be repositioned, resulting in R1 resisting and refusing care. Staff stated that they directly observed staff and R1's Hospice agency attempt to consistently reposition R1 to avoid pressure injuries, however R1's resistance prevented them from doing so each time.

R1's Hospice agency corroborated staff statements, informing that staff consistently attempted to turn R1 at regular intervals and also assisted them with turning R1 during visits, however R1 experienced progressive agitation due to pain, preventing them from being turned. This outside source additionally stated that R1's physical condition combined with becoming bed bound made their pressure ulcers inevitable, and the sores did not exist prior to R1's end stage condition. R1's Responsible Person informed that staff repositioned R1 as much as R1 would tolerate and were not neglectful in attempting to turn R1. Interviews with outside source medical professionals for other residents revealed that staff consistently turned other residents who were also at risk for pressure sores. R1 was unable to be interviewed due to passing away.

Records review revealed that R1 was receiving Hospice services. Shift reports, care notes, and shower skin sheets during the timeframe of complaint showed that staff tended to R1 regarding repositioning.

Regarding the allegation, Staff did not ensure residents' incontinence needs were met", it was alleged that Memory Care residents were not being assisted with toileting. Staff interviews were mixed regarding this allegation, with a majority of staff informing that toileting assistance was consistent and timely. Staff informed that toileting protocol was to assist or ask residents to use the bathroom approximately every two (2) hours. Some staff stated that residents in wheelchairs were not toileted as often as ambulatory residents, and other staff stated that communication between shifts resulted in confusion on when residents were being changed. Additional staff stated that at times the timelines were slightly extended, however, ultimately all residents were changed. Staff additionally noted that some residents refused to be assisted with toileting every two hours or had a behavior of inappropriately toileting around the building.

Outside sources interviewed did not express concerns regarding residents being assisted with incontinence care at the facility. One outside source noted that their respective resident tended to be combative when being given assistance. All outside sources informed of directly observing staff assist residents to the bathroom. (Continued on LIC 9099 p.3)

During unannounced facility visits LPA directly observed caregivers assisting residents with ambulating to the bathroom, and privately changing residents with incontinence briefs.

Regarding the allegation, "Staff did not observe residents for change in condition", it was alleged that staff did not follow Resident 1's care plan or notice when pressure sores began to develop. Staff interviews were mixed regarding this allegation, with a majority of staff stating that staff monitor residents for changes in condition and elevate the changes per protocol. One staff noted that a Medication Technician (Med Tech) elevated sores found on a resident's feet that had gone unnoticed by caregivers, indicating that the caregivers were not changing the resident's socks daily. Another staff offered that caregivers could fill out the communication logs in more detail, but did not state a specific incident where lack of detail resulted in and issue for a resident. All other staff informed that communication about residents' conditions were documented and elevated to management as well as residents' care providers and responsible parties.

Outside sources unanimously stated that the facility communicated changes in condition for residents. One responsible party noted that the facility had contacted them the day of interview letting them know that their resident was running low on a supplemental meal. No outside sources expressed concerns regarding the communication of changes in condition.

Review of facility records revealed resident charting notes of physical and behavioral changes that were documented and elevated to residents' doctors, hospice agencies, and responsible parties. The charting notes also noted when residents were temporarily placed on alert charting for increased monitoring.

Regarding the allegation, "Staff did not assist residents with personal care needs", it was alleged that residents were not being assisted with grooming and changing of clothes on the memory care floors. Staff interviews were mixed, as some staff informed that they did not observe un-groomed residents. Other staff confirmed that memory care residents were not consistently being helped with grooming tasks such as teeth/denture brushing, hair brushing, changing soiled clothes, and washing their faces. Staff interviews were consistent in that showering was being done with residents. Staff consistently stated that if a resident did not receive grooming help, the primary reason was due to refusals, including refusals to Hospice and/or Home Health providers.

(Continued on LIC9099 p.4)

While some corroboration existed regarding this allegation, less than half of the staff expressed concern regarding residents not being assisted with personal care needs.

Outside sources did not corroborate the allegation, informing that residents appeared groomed during visits with their respective residents. Outside sources did not express concern regarding resident grooming at the facility.

Regarding the allegation, "Staff did not provide resident(s) with housekeeping services", it was alleged that resident rooms were not being maintained clean by staff and that resident laundry was not being consistently washed. During interviews staff refuted this allegation, consistently informing that resident rooms were cleaned by housekeeping and caregivers. One staff member interviewed believed another staff may have covered up a resident's dirty sheets on a non-housekeeping day instead of washing them. One staff noted that if a shift is particularly busy there may be a delay in switching the laundry from the washer to the dryer, however this was a rare occasion and the resident's clothes were still washed by the end of the next shift. Staff also noted that due to cognition, sometimes Memory Care residents hid their clothes in unlikely places and caregivers did not see the items to collect for washing.

Outside source interviews revealed no concerns regarding resident laundry. Outside sources consistently stated that the facility was clean, organized, and that resident laundry was regularly washed.

During unannounced facility visits LPA directly observed a sample of resident rooms and common areas. LPA did not observe areas that were disorganized, unkempt, or in disarray. LPA did not observe any resident rooms that indicated laundry had not recently been washed.

Regarding the allegation, "facility smelled malodorous", it was alleged that the Licensee did not address the smell of incontinence on a Memory Care floor. Staff refuted the allegation during interviews, informing that while there was a smell of incontinence due to two residence having a behavior of inappropriately toileting, management made timely attempts to fix it. Staff stated that the carpets and furniture were cleaned after each incident, and the residents' care plans were updated regarding the behavior.

(Continued on LIC9099 p.5)

Changes of condition were communicated to the residents' responsible parties and medical providers, and the floor in the residents' room was replaced with vinyl flooring instead of carpet. Staff did not express concern regarding the Licensee's attempts to rectify the issue.

Review of facility records corroborated staff statements, revealing a vinyl flooring invoice for the residents' room in question. Shift reports and care notes during the timeframe in question revealed instructions for the residents to be assisted with toileting every hour, and before and after meals. Shift Report documents also showed that staff communicated when the residents had inappropriate toileting episodes and included requests for staff to keep the residents' floor clean/dry.

Four (4) of five (5) outside sources advised not observing any malodor at the facility. One outside source confirmed observing the malodor but stated that the facility cleaned the carpets, updated the flooring, and increased toileting for the residents in question in attempts to rectify the issue.

During an unannounced facility visit LPA Patterson directly observed the malodor in question, however, the carpets were actively being cleaned during the observation. LPA observed the new vinyl flooring in the room in question, corroborating management statements that the flooring had been replaced from carpet to vinyl. During subsequent unannounced visits LPA Patterson observed the memory care floor in question to be free from malodor or signs of inappropriate toileting.

Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Executive Director Rob Daynes, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.