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32 | Allegation: Staff left resident in soiled clothing for an extended period of time. The complaint alleges that resident (R1) was being neglected because 3rd party agency personnel frequently found the resident soiled when they arrived to provide services to the resident. LPA reviewed records and interviewed hospice personnel, facility staff, and two residents. Residents stated they are changed 3 to 4 times a day. The facility has a total of two live-in staff whom stated R1 received incontinence brief changes at 4:30 AM, 1:00 PM, and 4:30 PM, and occasionally the resident had their brief changed at 6 PM. Both staff live in the home, and the primary caretaker's shift ends at 8PM. Therefore, the resident was not changed until the following day at 4:30 AM. Staff stated that Administrator never provided incontinence care or pressure injury training, but learned through past hospice nurses that provided care for residents. Administrator was not cooperative with interview questions. According to hospice personnel R1 had been receiving daily visits since June 1, 2026 for stage 2 pressure injury to the coccyx and deep tissue injury to right hip. After admission to hospice R1 developed left heel blister, redness to right heel, and stage 2 at right hip developed from the deep tissue injury originally noted at admission. Observations made by hospice personnel revealed that facility staff were not attending to R1's soiled brief, and despite attempted care education of caregivers they continued to show deficits in care and suspected neglect was communicated to licensee/Administrator, but Ms. Duenas was non-responsive regarding standards of care. The resident died on June 27, 2026. The allegation is supported.
Allegation: Staff are not properly utilizing incontinence supplies. It is alleged caregivers use incontinence supplies inappropriately in a way that promotes or encourages infection or caused concern for resident safety. Two residents were interviewed. One resident stated they heard that R1 did not have enough incontinence supplies. The facility has two live-in staff. Staff interviews revealed that hospice agency supplies resident (R1) 2 bags of incontinence briefs per week, each bag has 15 briefs. Staff stated R1 did not have enough incontinence wipes, briefs, and spray. Caregivers stated Administrator called R1's family requesting supply of briefs, and also called the pharmacy. During the visits, incontinence supplies were checked. Resident (R1's) supply was limited. The findings indicate the Licensee/Administrator never purchased extra supplies for resident (R1). The allegation is supported.
Based on observation and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22, Division 6. See LIC 9099D.
Exit interview was conducted with Administrator Ana Duenas. A copy of the report and appeal rights were provided. |