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32 | Based on interviews conducted during the course of this investigation, it was learned that there wasn't a cohesion within the core group of facility caregivers, which there were (3) main facility staff persons at this time. It was learned that on at least (1) occasion, the oncoming staff came on and discovered that the scheduled staff for the previous shift had left the facility without notification to the oncoming shift or the facility administrative team. It was learned that the facility residents had been left alone, without any facility staff care and supervision, for an unknown amount of time before the oncoming shift finally arrived to take over.
It was learned that there were notifications, in the form of phone calls and text messages, that were exchanged with the facility designated Administrator in regards to this incident.
Based on interviews conducted during the course of this investigation, it was learned that there was evidence to support that facility residents were left in soiled depends for extended periods of time leading to the development of pressure injuries and other health related injuries. It was learned that these other possible injuries led facility residents to be diagnosed with Urinary Tract Infection (UTI) as well.
It was learned that these types of incidents would lead facility staff persons to have several verbal exchanges, which were highly unprofessional, to take place in front of the residents at times. It was learned that facility staff persons would raise their voices, yell, and even use profanity as well while all in the presence of the facility residents.
As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegations were valid because the preponderance of the evidence standard had been met.
The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.
Appeal rights were printed and a copy was left with the facility designated representative at this time.
Exit Interview |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
11/15/2024
Section Cited
CCR
87466 | 1
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7 | 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 | 1
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7 | The facility designated representative stated that all facility staff will be trained, for no less than (2) hours in duration, from a third party vendor on the topic of proper care and supervision at all times 24 hours/7 days a week, dealing with and preventing pressure injuries, and dealing with and preventing UTIs. |
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14 | 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.
This facility was found to be deficient as evidenced by information concluding that the sole facility staff member left the premises so that facility residents were unsupervised for an unknown amount of time. In addition, facility staff did not regularly change and check on the residents to prevent the emergence of pressure injuries and other physical issues. This presented an immediate threat to the Health, Safety, and Personal Rights of residents in care. | 8
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14 | A statement of correction, along with documented proof of vendorized staff training, will be completed and submitted into CCL by the due date. |
Type A
11/15/2024
Section Cited
CCR
87468.1(a)(1) | 1
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7 | Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
This facility was found to be deficient as | 1
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7 | The facility designated representative stated that all facility staff will be trained, for no less than (1) hour in duration, from a third party vendor on the topic of maintaining professionalism to make sure that facility residents' personal rights were always upheld. |
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14 | evidenced by information concluding that facility staff members were arguing and engaing in disputes in front of the residents which presented an immediate threat to the Health, Safety, and Personal Rights of residents in care. | 8
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14 | A statement of correction, along with documented proof of vendorized staff training, will be completed and submitted into CCL by the due date. |