Facility Evaluation Report

While investigating Complaints 59-AS-20230731122901 and 59-AS-20230717132508, the following deficiencies were observed:

1. The facility staff (S1) that works overnight does not provide any incontinent care to the residents. S1 stated they do not check to see if a resident who requires assistance with incontinence care nor does S1 change the resident out of soiled clothes and briefs. Interviews show S1 does not respond to residents who request assistance during the overnight hours. The facility file does not have any staff training required by Title 22 regulations regarding night supervision. There is no proof S1 has first aid training and training to assist in caring for residents in the event of an emergency. California Health and Safety Code states the licensee may designate a qualified substitute in place of the administrator who has to be present on the premises 24 hours per day and that qualified substitute shall have qualifications adequate to be responsible and accountable for the management and administration of the facility. The staff member on duty overnight does not meet these requirements. There is no proof of any training to ensure the person is qualified.

2. A resident (R1) was on home health during the resident’s stay. The facility is required to have a copy of a written agreement of what the facility staff are to do and what the home health care agency is supposed to do. That was not found in the resident’s file .

3. The facility is required to have ongoing communication between themselves and the home health care agency. That was not found in R1’s file.

4. R1 developed a pressure injury during a hospital stay and was admitted with the pressure injury. The facility did not document R1 had a pressure injury. The licensee is required to do a preappraisal and a reappraisal when there is a change in condition. There is no documentation stating R1 had a pressure injury and what was being done about it.