Brightwater Senior Living of Highland (DBA)

Allegation investigated: Staff mishandled a resident's medication while in care

This unannounced visit by Amy Goldenberg, Licensing Program Analyst (LPA), is to initiate the 10 day visit to investigate the above-mentioned complaint allegation. LPA met with Resident Care Coordinator Ruth Villa, LVN and disclosed the elements of the complaint investigation. Investigation consisted of interview with Ruth Villa and review of the records for one (1) resident (R1). It is alleged that R1 was given the wrong dose of a narcotic pain medication. Interview with Resident Care Coordinator revealed that the allegation is accurate. R1 had a routine order for 5 mg of the medication Norco. On 09/11/2023 a nurse dropped off medication intended for R1 as post-operative pain management for after a scheduled upcoming surgery. The medication received by the facility was for 10 mg of the medication Norco, and did not have a physicians order or direction provided. The facility mistakenly thought that the medication was a refill of the 5 mg routine order of the medication Norco. The facility administered the 10 mg dose of Norco with out an order from 09/11/2023 through 09/19/2023 at 2200. Substantiated The facility has provided their plan of correction to LPA which has been implemented and was to conduct an in-house medication cart audit. The facility has implemented three (3) weekly inter-shift medication cart audits. The facility has conducted an in-service training to all medication technicians/nurses on 09/25/2023. Based on the available information the complaint allegation is being substantiated. LPA has determined the complaint allegation as valid and that a violation has occurred. A copy of this report along with appeal rights are being reviewed with, and furnished to the facility representative. Please see LIC 9099D.the state’s words, verbatim · CDSS document, Oct 4, 2023 · control 56-AS-20230926135046

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(5)(A) · Plan of correction due date: Oct 5, 2023

...Assistance with self administered medications shall be limited to the following: Medications usually prescribed for self-administration which have been authorized by the person's physician. The facility did not meet this requirement as evidenced by providing R1 with the wrong dose of the medication Norco 09/11/2023 through 09/19/2023. This poses a potential health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Oct 4, 2023

Plan of correction: In addition to plan of correction measures implemented by the facility it is agreed that a pharmacy audit will be conducted by an outside pharmacy. Resident Care Coordinator agreed to provide scheduled date by POC due date of 10/04/2023 to complete the facility plan of correction. Copy of medication audit to be provided to CCL once completed.

Allegation investigated: Neglect by staff resulting in a resident sustaining a pressure injury while in care.

Licensing Program Analyst (LPA) Javina George made and unannounced visit to deliver findings for the allegation noted above. LPA met with Execuitve Director Marguerite Crockem and explained the purpose of the visit and the elements of the allegation. The department investigated the allegation, the investigation consisted of observations, interviews and records review. Resident #1 (R1) was admitted to the facility on 05/02/2014 without any noted pressure injuries or wounds. On 01/02/2020, Staff #1 (S1) reported to the Residential Care Manager (S2) that R1 had a wound located on their left heel and described it as "an about a 3-inch by 3-inch circle with blackness inside the circle and redness around it". After seeing the wound, S2 did nothing and waited until the following day. At that time is when S2 assessed the area, then notified R1’s responsible party, and spoke with them about R1 receiving hospice services. However, there was no additional follow up with R1’s Primary Care Physician. Interview revealed S2 believed a fax had already been sent to the Doctor. *** Continued on 9099C Substantiated On 01/03/2020, the doctor gave orders to keep the foot elevated in order to release pressure and asked to see photographs. Per the Acting Executive Director, a photo was not sent as they believed it would be a HIPPA violation. Additional interviews revealed, Staff # 3 (S3) revealed that they would change and adjust R1’s socks but would not check R1’s heels. S3 observed red stains in R1’s bedding but did not check to see where it was coming from. S3 assumed R1 had an ingrown toenail. R1 was known to pick their skin and S3 assumed the blood could have been from that as well. Investigation did not reveal that facility staff followed the doctor’s request to evaluate or stage the pressure injury/wound. Investigation revealed that between 01/02/2020 through 01/07/2020, R1 was reported to not receive any treatment for the wound on their left heel other than having their foot elevated and the area cleaned by facility staff. Per S2, staff are responsible for conducting skin integrity checks during resident showers. R1 received showers twice a week until they were admitted to hospice on January 7, 2020. However, staff did not report seeing any skin integrity issues until 01/02/2020. This resulted in nine (9) care staff receiving written warnings for not being aware of the wound. On 01/07/2020, hospice services were initiated, and the nurse assessed the wound. At this time the wound was described as an "unstageable decubitus ulcer to the right heel" that was about 6 cm (2.36 inches) by 6 cm (2.36 inches) and it was covered by necrotic tissue. S1 was present during the assessment and stated that "the wound looked the same as it did on 01/02/2020”. There is sufficient evidence to show neglect by facility staff, to provide proper care and supervision of R1. Therefore, the allegation is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. An immediate civil penalty of $500 is being assessed. In accordance with H&S Code Section 1569.49(e), the determination of additional civil penalties for a violation that resulted in a serious injury to the resident, is pending and under review by the Department. An exit interview was conducted, a copy of this report was reviewed and provided along with the 9099C, 9099D, appeal rights, and LIC421IM was given to Executive Director Marguerite Crockem.the state’s words, verbatim · CDSS document, Sep 12, 2023 · control 18-AS-20200226162945

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87465(a)(1) · Plan of correction due date: Sep 26, 2023

87465 Incidental Medical and dental care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care... (1) The licensee shall arrange or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: The Licensee failed to ensure that R1 received treatment for the wound in a timely manner. This posed a potential health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 12, 2023

Plan of correction: The Licensee agrees to conduct an inservice on skin breakdown, and body checks. Proof of completed POC is to be submitted to to the department by 5pm on the due date indicated.

Allegation investigated: Staff did not apply ointment as prescribed.

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to initiate the investigation of and deliver findings on the above complaint allegation. LPA met with Mrs. Crockem. The investigation included interviews with resident and staff and records review. It is alleged that Staff did not apply ointment as prescribed. LPA reviewed records and found that Resident 1 (R1) was first seen on 12/26/22 for a rash an nonspecific skin eruptions. Witness and staff interviews confirmed that R1 continued to have skin issues throughout and was last seen on 07/15/23 and treated for scabies. LPA reviewed medication records and found scabies medication Permethrin cream was administered on 07/28/23 through 07/30/23 and 08/3/23 through 08/5/23. While staff interviewed stated that the cream is administered one time every two weeks, recorded administration of the cream does not follow the two week schedule. Furthermore, LPA interviewed R1 who is able to verbalize their needs. Review of medication record further reveal that as needed medication for rash or itching was not administered. LPA found that allergy medication for itching was started on 7/16/23 and administered only on 8/11/23 through the end of this report. Substantiated Based on the information obtained during the investigation, this agency has substantiated the complaint allegation as valid and that a violation has occurred based on the preponderance of available evidence. This poses a potential health and safety risk to client in care. Refer to LIC9099-D for deficiency cited. An exit interview was conducted and a copy of this report, LIC9099-D, and appeal rights were provided to Executive director Marguerite Crockem.the state’s words, verbatim · CDSS document, Aug 14, 2023 · control 56-AS-20230807153844

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(b) · Plan of correction due date: Aug 31, 2023

(b) If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication. This requirement was not met evidenced by: LPA reviewed R1 medication administration records that are not the same as the medical order. Records further reveal that R1 was administered allergy medication for itching once on 08/11/23the state’s words, verbatim · CDSS document, Aug 14, 2023

Plan of correction: Facility shall conduct a medication audit, specifically for creams and medication applied topically. Medication Technician training review to be completed and in-service record to be submitted to the DEpartment no later than end of POC date.

Allegation investigated: Resident sustained unexplained injury while in care. Staff leave residents in soiled diapers for extended periods of time. Residents are being neglected while in care. Staff failed to provide residents with clean linens.

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to investigate the complaint allegations above and deliver findings. LPA and met with Amber Nelson, Memory Care Director (MCD), who was informed of the reason for today’s visit and the elements of the allegation. Executive director (ED) Marguerite Crockem arrived shortly and was informed of the purpose the visit however ED left the memory care unit before the conclusion of the investigation. The investigation included LPA observations, staff and residents interviews, and records review. Allegation 1: R1 sustained unexplained injury while in care. Interviews with staff deny that bruising was observed on R1's hands nor has their spouse who visits daily has spoken to staff about the bruising. Staff interviews also reveal that R1 is under hospice care and is visited by a shower nurse and a registered nurse regularly. LPA reviewed records showing that hospice visited R1 on 5/8/23, 5/9/34, 5/11/23, 5/15/23, and 5/23/23 and there are noted concerns from hospice during these visits. This allegation is therefore unsubstantiated. Unsubstantiated Allegation 2: Staff leave residents in soiled diapers for extended periods of time. Resident interviews deny that they are left wet in soiled diapers for extended periods of time. Interviews with residents further reveal that they do not feel wet during this time. LPA observed residents to be clean and observed staff assist multiple ambulatory and non-ambulatory residents to the bathroom. LPA observed R2 ambulating with assistance. LPA visited rooms and found the rooms to be free from odor. This allegation is unsubstantiated. Allegation 3: Residents are being neglected while in care. Resident interviews deny that they are being neglected. Interviews with residents further reveal that staff are fine and they are kept clean. LPA observed residents to be clean and tidy. Interview with staff confirm that there are usually two care staff working during NOC shift and four staff during AM and PM shifts. LPA inspected resident rooms and found them to be tidy and not cluttered. This allegation is therefore unsubstantiated. Allegation 4: Staff failed to provide residents with clean linens. LPA inspected and observed room numbers 6, 7, 8, 10, 21, and 22 and found them to have clean linens. Interview with staff confirm that linens are provided by the resident and their care staff are responsible for washing the laundry as needed. LPA reviewed records showing that residents also have a scheduled laundry service 1-2 times a week. This allegation is unsubstantiated. A finding of UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted with Ms. Nelson and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 26, 2023 · control 56-AS-20230523152910

Type of visit: Collateral

Licensing Program Analyst (LPA) Bernadette Allen and Magda Malcore conducted an unannounced visit to the facility to interview resident 1 (R1) regarding complaint investigation 56-AS-20221102154307. LPA's met with Marguerite Crockem who was informed of the purpose of the visit. During the visit Marguerite Crockem informed LPA's that the resident was moved to another facility because of needing a higher level of care and during the visit details of the residents needs were discussed. The LPA's were given the name and number of the new facility where the resident was moved. An exit interview was discussed and a copy this report was provided to Marguerite at the conclusion of the visit.the state’s words, verbatim · CDSS document, Feb 21, 2023

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced case management visit to this facility regarding an report received by the Department on 1/20/2023. LPA met with memory care resident manager (RM) Amber Nelson. The following is a summary of the incident: On 1/20/2023, LPA received communication from the facility regarding the placement of Resident 1 (R1). LPA was also informed that R1 was yelled at by staff in the facility. During today's visit, LPA discovered that R1 was not yelled at by staff on 1/20/23. LPA discovered that R1 was in an outing when they had an incident. Records reviewed show that the facility has been trying to get in touch with R1's responsible party to seek a more appropriate setting for R1. No deficiencies were cited during today's visit. An exit interview was conducted where a copy of this report was provided to Ms. Nelson.the state’s words, verbatim · CDSS document, Jan 23, 2023

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) Anna Bueno and Michelle Echeverria conducted an unannounced visit to this facility to discuss an incident report that was received by the Department on 12/13/22. LPAs met with memory care resident manager (RM) Amber Nelson. The following is a summary of the incident: On 12/8/22, Staff 1 (S1) was heard by RM and Staff 2 (S2) yelling at Resident 1 (R1). RM went out of their office and observed S1 holding the arm of R1 and yelling and cursing at them. RM and S2 separated S1 and R1. RM and S2 brought R1 inside RM's office. S1 stated that they were leaving work and was allowed to collect their personal items. On their way out of the facility, S1 went inside RM's office and said that they would hurt R1. Records reviewed during today's visit show that S1 did not return to work since 12/8/22 and was separated from this facility as of 12/14/22. No deficiencies were cited during today's visit. An exit interview was conducted where a copy of this report was provided to Ms. Nelson.the state’s words, verbatim · CDSS document, Jan 13, 2023

Allegation investigated: Staff did not provide adequate supervison to resident resulting in resident sustaining injuries while in care. Staff did not ensure that resident's toileting needs were met while in care. Staff did not administer resident's medication(s) as prescribed. Staff did not seek medical attention for resident in a timely manner. Staff did not adhere to resident's care plan. Staff do not have the adequate skills to transport resident(s) in a safe manner. Staff did not properly manage resident's incontinence care resulting in infection.

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to investigate the complaint allegations above and deliver findings. LPA identified herself to business office manager Danielle who was notified of the reason for today’s visit and the elements of the allegation. Executive director Marguerite Crockem arrived shortly and was informed of the purpose of today's visit. The investigation included LPA observations, staff and residents interviews, and records review. Resident 1 (R1) did not want to speak with LPA. Allegation 1: Staff did not provide adequate supervision to R1 resulting in R1 sustaining injuries while in care. Records reviewed show that R1 was discovered by staff to have a laceration on their leg and was sent to the hospital. Interviews with staff and third parties revealed that R1 was by themselves in their room when they were found with laceration. Third party interviewed disclosed that R1 was on their mobile chair when the incident occurred however there were no actual witnesses to the incident but that it occurred inside R1’s room. This allegation is unsubstantiated. Allegation 2: Staff did not ensure that R1's toileting needs were met while in care. LPA observed two staff Unsubstantiated change resident’s soiled brief and clothes immediately after a third-party visit. Interviews with witnesses reveal that R1 is clean and dry when seen by witnesses. Resident interviews reveal that they call staff when they need toileting assistance. This allegation is unsubstantiated. Allegation 3: Staff did not administer resident's medication(s) as prescribed. Records reviewed and LPA observations revealed that medication record and medication match on dates when R1 was not in the facility. Staff and witness interviews reveal that medication is administered accordingly, sometimes with apple sauce but whole and uncrushed to aid R1 swallow the medication. Resident interviews reveal that they call staff when they are receiving their medication timely. This allegation is unsubstantiated. Allegation 4: Staff did not seek medical attention for resident in a timely manner. LPA observed staff using mobile devices and walkie talkies at work. LPA observed communication devices in use and observed nurses respond to staff request for assistance. Interviews with staff reveal that residents are sent to the hospital after nurse assessment. Resident interviews that they can contact staff when they need immediate medical assistance by pushing their pendant. This allegation is unsubstantiated. Allegation 5: Staff did not adhere to resident's care plan. Records reviewed show that R1’s care plan was updated less than 45 days ago. Interviews with staff and third party confirm that R1 hired a personal caregiver not associated to this facility less than 45 days ago. LPA observed several staff assist R1 multiple times during today’s visit. This allegation is unsubstantiated. Allegation 6: Staff do not have the adequate skills to transport resident(s) in a safe manner. LPA observed 2 staff transfer R1 manually. Witness interview shared that they observed staff to safely transfer residents. Resident interviews reveal that they feel comfortable with staff transferring them to and from their beds and chairs. This allegation is unsubstantiated. Allegation 7: Staff did not properly manage resident's incontinence care resulting in infection. LPA observed 2 staff change resident’s soiled brief and clothes immediately following a third-party visit. LPA could not find corroborating paperwork indicating that R1 developed an infection from lack of incontinence care. Resident interviews reveal that their briefs are regularly changed by staff and residents can get in touch with staff by way of their pendant necklace. This allegation is unsubstantiated. A finding of UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted with Mrs. Crokem and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 19, 2022 · control 56-AS-20221013102111

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(5) · Plan of correction due date: Oct 20, 2022

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: Staff interviews that one scheduled medication is pre-poured. LPA observed pills for days 20 and 21 were not inside the medicine bubble pack.the state’s words, verbatim · CDSS document, Oct 19, 2022

Plan of correction: Licensee shall conduct a random medication audit for 10 percent of the current population. Proof shall be submitted to the Department no later than the end of the POC date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility for the purpose of delivering an amended report to complaint control number 56-AS-20221013102111 Findings for complaint control number 56-AS-20221013102111 remains as unsubstantiated. Refer to LIC 9099 for details on this complaint. No deficiencies were citied during today’s visit. An exit interview was conducted where this report was discussed with, and a copy was provided to Mrs. Crockem at the conclusion of the visit.the state’s words, verbatim · CDSS document, Oct 19, 2022

Allegation investigated: Facility mismanaged resident's medications.

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to investigate the above mentioned complaint allegation and deliver findings. LPA identified herself to Health Services Coordinator Angie Lafler who was notified of the reason for today’s visit and the elements of the allegation. Executive director Marguerite Crockem arrived shortly and was informed of the purpose of today's visit. The investigation included staff interviews and records review. It is alleged that the Facility mismanaged resident's medications. On 9/15/22, Resident 1 (R1) ran out of one (RX) of their two scheduled medication. Records reveiwed showed that the facility continued to update the medication record for RX as DNA-Drug not available on 9/16/22 and 9/17/22 and as HLD-Medication on Hold from 9/18/22 through the morning of 10/6/22. The RX was filled in the evening of 10/6/22 and R1 has been taking the RX consistently to date. Records reviewed and staff interviews revealed that the facility did not communicate with R1's responsible party between 9/15/22 through 10/4/22 that the RX has ran out and has not been filled. Based on the information, this complaint in substantiated. Substantiated A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. This poses and immediate health and safety risk to residents in care. Refer to LIC809-D for deficiency cited. An exit interview was conducted where this report, LIC809-D, and appeal rights were discussed with and provided to Ms. Lalfler.the state’s words, verbatim · CDSS document, Oct 12, 2022 · control 56-AS-20221006095346

From the deficiency page — Deficiency type: Type A · Section cited: CCR 874659(d)(1) · Plan of correction due date: Oct 13, 2022

If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms...Facility staff shall contact the resident's physician prior to each dose, describe the resident's symptoms, and receive direction to assist the resident in self-administration of that dose of medication This requirement was not met as evidenced by: Records reviewed and staff interviews confirmed that Resident 1 (R1) scheduled medication ran out on 9/15/22 and the facility did not communicate with R1's family that the medication has not been filled until 10/5/22. This poses and immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 12, 2022

Plan of correction: Licensee shall submit proof of training that residents are not without medication and that responsible parties are notified accordingly. Proof of the correction will be submitted to the Department before the end of POC date 10/13/2022. Prior to today's visit, Health Services Director verfiied that a re-training has been scheduled for med tech staff and will be completed no later than 10/20/2022.

Allegation investigated: Staff served resident an eviction letter containing incorrect information Staff did not provide resident with reappraisal

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to commence a complaint investigation and deliver findings on the above allegation. LPA identified herself to executive director Marguerite Crockem, who was notified of the reason for today’s visit. Allegation 1: The allegation is that staff served resident (R1) an eviction letter containing incorrect information. On 8/1/2022, this facility sent a copy of R1's eviction letter copy to the Department with the Long-Term Care Ombudsman's phone number as (909)891-3928 and the Department's number as (951)248-2222. Allegation 2: Staff did not provide resident with reappraisal. Records review show that R1 physian's report was completed on 8/30/21, a facility history and physical report was updated on 4/30/22, and the quarterly service plan was completed on 7/12/22. Based on the available information, we have found the complaint allegation is UNFOUNDED. **************continued on LIC 9099-C************** Unfounded Based on the available information, we have found the complaint allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. An exit interview was conducted where this report was discussed, and a copy provided to the Executive Director.the state’s words, verbatim · CDSS document, Aug 25, 2022 · control 56-AS-20220817151703

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Rayshaun Nickolas and Anna Bueno conducted an unannounced visit to the facility for a required annual inspection, with an emphasis on the infection control domain. LPAs met with Jasmine Ridenour, Acting Executive Director and Angie Lafler, Health Services Director. The facility submitted a mitigation plan to Community Care Licensing (CCL) to mitigate the spread of COVID-19 in the facility. Single entry point and a sign-in policy has been designated for universal entry screening. The facility also documents daily temperature and COVID-19 symptom checks for all visitors while residents are subject to routine symptom screening and regular observation for any change in condition. Continued weekly routine testing for staff is still observed. LPAs observed all staff are properly fitted with face coverings. LPAs Nickolas and Bueno toured the facility’s dining areas and common rooms. Ridenour and Lafler verified that the smoke detectors and fire alarms are maintained on a call system and monitored by an outside vendor. Charged fire extinguishers are checked monthly, and the most recent inspection was in February 2022. LPAs observed hand sanitizer throughout the facility. Ridenour also confirmed that the facility has an adequate supply of Personal Protective Equipment (PPE) and cleaning and disinfectant provisions. LPAs Nickolas and Bueno observed no health and safety concerns at the time of visit. Based on observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report was discussed, and a copy of this report was also provided to Ridenour at the conclusion of the inspection.the state’s words, verbatim · CDSS document, Mar 25, 2022

Allegation investigated: Staff did not respond to resident's calls for help. Facility has not reimbursed resident for cost of lost property. Staff are not meeting resident's showering needs. Staff are not meeting resident's personal hygiene needs. Staff handled resident in a rough manner.

Licensing Program Analysts (LPAs) Anna Bueno and Bernadette Allen conducted a complaint visit to deliver findings on the above allegations. LPAs met with Marguerite Crockem, Executive Director, and explained the nature of today’s visit. LPA Bueno conducted the investigation and interviewed staff and resident and reviewed facility files. Allegation #1: Staff did not respond to resident's call for help. Records reveal that care services continued regardless of whether the call button was operational. This allegation is unsubstantiated. Allegation #2: Facility has not reimbursed resident for cost of lost property. Reporting Party (RP) informed LPA Bueno that resident received a reimbursement check for the lost property. This allegation is unsubstantiated. ***CONTINUED ON LIC 9099-C*** Unsubstantiated Allegation #3: Staff are not meeting resident's showering needs. Interviews with RP and staff reveal that Resident 1 (R1) refuses showers and prefers bed baths. This allegation is unsubstantiated. Allegation #4: Staff are not meeting resident's personal hygiene needs. Interviews with staff and RP reveal that R1 would refuse services. This allegation is unsubstantiated. Allegation #5: Staff handled resident in a rough manner. Interviews with RP and staff reveal that R1 was not handled in a rough manner. LPA Bueno was not able to find enough evidence that the incident did or did not occur. This allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time. No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed with and a copy was provided to the Executive Director.the state’s words, verbatim · CDSS document, Nov 19, 2021 · control 18-AS-20210922080754

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(i)(1)(B) · Plan of correction due date: Nov 19, 2021

(i)(1)(B): Facilities shall have signal systems...All facilities licensed for 16 or more..Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal... This requirement is not met as evidenced by: Based on observation and interview, the licensee did not ensure that R1's call system was operable.the state’s words, verbatim · CDSS document, Nov 19, 2021

Plan of correction: The licensee shall ensure R1's call button is operating or an alternative call system is available. The licensee has an operable call button for R1 as of 9/20/2021 1:01 PM.