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32 | During the investigation, LPA Charitra interviewed staff, reviewed R1’s documentation and file, and inspected the bedroom. Interviewed staff indicated that R1 was admitted back in January of 2016 as an “independent” resident. The file review revealed that the continence products will not be used, although according to staff, R1 required briefs and pull-ups. The interviews also revealed that R1 had a history of urinating in his/her clothes. This resulted in an increase in the frequency of checks and elevating R1’s condition to a Level 2, requiring the use of additional changes of underwear and the use of pull-ups. Nevertheless, the licensee failed to update the physician report and/or to reappraise in order to develop an appropriate care plan to address R1’s health changes.
The department received several reports that on the day of the incident, the room where R1 was found was disheveled and there was a strong smell to urine. R1’s room was inspected by LPA Charitra on October 27, 2021, 10-days after the incident. The windows were closed, the room was in disheveled and there was a strong smell to urine. According to the Administrator, the windows were closed due to a storm that took place on October 24th, a week and after the incident occurred. The mattress had been removed and yet the urine smell was strong.
On November 10, 2021, almost three weeks after the incident, LPA Charitra and Investigator Phung conducted another unannounced visit to the facility and observed the resident’s room. The bed frame had been removed, and windows were observed to be open. The urine smell is still in the room. The facility incident report only acknowledges that the resident had an accident on 10/17/2021; however, the information collected provides preponderance of evidence to indicate that R1’s had been experiencing incontinency for some time.
Based on the above information and documentation, it was determined that the licensee failed to document R1’s health changes and consequently failed to meet R1’s needs and failed to provide appropriate care and assistance. Furthermore, the licensee failed to assist resident with incontinence care and failed to maintain the resident’s room in sanitary condition. The preponderance of evidence standard has been met; therefore, these allegations are Substantiated.
The following deficiency was cited per CA Code of Regulations Title 22-refer to the 9099D and appeal rights were provided. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
11/29/2021
Section Cited
HSC
87466 | 1
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7 | 87466 Observation of Resident, The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. | 1
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7 | Facility shall develop a written plan of correction (POC) describing how facility shall ensure compliance with 87466. Staff shall conduct additional training if needed. POC shall include measures to be implemented to prevent a repeated occurrence and submitted to CCLD before due date. |
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14 | Violation of this regulation is evidence by staff interviews indicating awareness that R1 had experienced health changes, among them a history of urinating in his/her clothes. This awareness is also shown by a single document indicating that the level of care had changed to a Level 2, requiring the use of additional changes of underwear and the use of pull-ups. Nevertheless, the licensee failed to update the physician report, failed to reappraise and failed to develop an appropriate needs and services plan to address R1’s health changes. | 8
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Type B
11/29/2021
Section Cited
CCR
87303(a)(1) | 1
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7 | 87303(a)(1) Maintence and Operation, The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition
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7 | Facility shall develop a written plan of correction (POC) describing how facility shall ensure compliance with 87303(a)(1). POC shall include measures to be implemented to prevent a repeated occurrence and submitted to CCLD before due date. |
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14 | Violation of this regulation is evidence by several eyewitness who have indicated that the room was in dishevel, the mattress was soaked in urine, and the room was unsanitary. These reports were confirmed by the LPA observations on 10/27/2021, when the room was in dishevel, and had a strong urine smell, and 11/10/2021, when the room was still retaining a strong odor to urine even after the windows had been opened and facility had a chance to clean. | 8
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13 | On November 23, 2021, Licensing Program Analyst (LPA) Komal Charitra met with Resident Care Director, Deanna Chan to deliver the findings for the above allegations.
Regarding the allegation that resident was not receiving appropriate diabetes care. On October 17, 2021, Complainant states Resident (R1)’s glucose level was significantly elevated to 407 upon emergency personnel arrival. According to Administrator, R1 is independent and is able to manage and take his own medication.
A review of the resident’s file, to include the physician’s report, and interviews, indicates that R1 had been cleared to self-administer his own testing and medications. Staff interviews indicated that R1 was aware of the medications to take, when to take them, and when to change or re-order medication.
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| Unsubstantiated | Estimated Days of Completion: |
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