It was reported that the laundry room was stacked high with laundry and they didn’t have any laundry detergent.

LPA reviewed an Instacart delivery receipt dated 08/31/2024 3:28 PM for Tide laundry detergent for a cost of $90.17.

3 of 4 staff stated that they did run out of laundry detergent, the laundry did pile up, but the administrator had detergent delivered. 1 of 4 staff stated that they still had detergent but the new staff did not understand how to use the dispenser.

Administrator stated Staff called me and said they were going to run out. I had sent someone to the laundry mat to do the sheets. I had detergent delivered via Insta cart the same day from Costco, they did not run out they said they still had some.

It was determined that the facility did run out of laundry detergent and as a result the laundry was piled up in the laundry room. This allegation is substantiated.

Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview conducted and a copy of the report was provided to administrator Stacey Baxter.

It was reported that a resident fell and the facility refused to send the resident out until two days later.

Administrator stated Resident 1 (R1) fell on 8/25/24 R1 was found on the floor, denied being hurt. Hospice was contacted and they said to give whatever R1 needs to be comfortable. Hospice came to the facility that day to evaluate R1. On 8/27/24 R1 was doing well walking around. On 8/30/24 R1 was not bearing good weight, EMS was called and R1 was sent out because that is out of their hospice diagnosis. R1 came back the same day with no new orders.

It was determined that R1 fell on 08/25/2024. R1 is on hospice, hospice evaluated R1 at the facility. R1 was sent out due to not being able to bear weight but returned the same day back to the facility with no new diagnosis. This allegation is unsubstantiated.

Staff did not meet a resident's incontinence needs. - UNSUBSTANTIATED

It was reported that Resident 3 (R3) was in an employee bathroom with dried stool on them and tried to clean themselves up with hospital gloves. No peri care provided.

LPA reviewed the care tracking sheets for R1, R3, and R4 for the month of August 2024 and found that all residents had been checked for continence care every 2 hours every day except one day during the hours of 5:00 PM through 9:00 PM for R1 and 7:00 PM through 9:00 PM for R3 and R4 care was not recorded. The ADL was not recorded on the same day of the month for all three residents.

During staff interviews it was learned that is not out of the ordinary for Resident 3 (R3), they like to clean themselves independently and staff help R3 when needed. Staff stated that residents are toileted every 2 hours or as needed but some residents refuse which is their right.

Administrator stated Residents can go into the bathroom and clean themselves. Residents are toileted according to their care plan. If a resident is really incontinent, we put them on 2 hours checks.

This allegation is unsubstantiated.

It was reported that residents have pressure ulcers and when staff asked for barrier cream they were told they couldn’t have any and they just put a bandage over the wound.

Staff interviews revealed that R2 had a stage 1 pressure ulcer on their tailbone and on their heal and are being treated by hospice. Hospice supplied the boot protectors for R2’s heels. Staff rotate R2 every 2 hours. R2 has been prescribed a barrier cream by their physician.

Administrator stated On 8/24 Resident 2 (R2) had skin break down, notified by hospice stage 1. Hospice is providing the wound care for R2. If the resident has been prescribed a cream the med tech will apply. The staff are turning R2 and applying the cream.

This allegation is unsubstantiated.

Staff are not ensuring that residents are swallowing their medications once dispensed. - UNSUBSTANTIATED

It was reported that staff do not ensure residents have swallowed their medications. Stated residents have whole pills still in their mouths and on their lips.

Staff stated when they dispense medications to residents, they will ask a resident to open their mouth or wait for them to talk to staff to make sure they have swallowed their medications.

Administrator stated Staff stay with the residents and monitor and see them swallow their medications.

This allegation is unsubstantiated.

It was reported that at night there are no snacks available. There is bread and butter, no fruit or anything for a sandwich, not even juice.

Staff stated the cook has been preparing small sandwiches for the NOC shift and leaving snacks out. Staff have access to it all of the times.

Administrator stated the kitchen is open and staff have the keypad combination to get in at all times. Staff can go in the kitchen and fix something for the residents, they can fix a sandwich or anything the resident asks for.

This allegation is unsubstantiated.

There are no clean dishes available during NOC shift. - UNSUBSTANTIATED

It was reported that a NOC staff went in kitchen to get silverware and nothing had been cleaned, the dishes were stacked up.

Staff stated that the cook cleans the kitchen every night and dishes are available to the NOC shift.

Administrator stated All dishes are put away and the kitchen is cleaned spotless before kitchen staff leave at 7:00 pm. If we have stragglers that are slow eaters, staff will place those dishes in the kitchen on a cleaning cart and they are washed in the morning.

This allegation is unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED.

An exit interview was conducted. A copy of the report was provided to Patricia Goebin-Cuellar.