complaint·February 2, 2023

It was alleged resident was left in wet diapers for extended periods of time and staff failed to meet resident's hygiene needs . However, based on interview with 3 of 5 staff, R1's hospice agency conducts visit daily and assist R1 with toileting and dressing. S4 and S5 stated that two rounds are conducted per shift. LPA discovered during an interview with S4 and S5 that residents who are under hospice are also changed as needed by caregivers. It was alleged resident was not adequately fed while in care. On 1/16/2023, LPA L. Fontanilla reviewed R1’s hospice notes from April 2021 to August 2021. Based on records reviewed, R1 had a fair appetite. R1 preferred to pick own food and refused assistance from staff with meals. Notes also indicate that R1 was consuming 30-50% 3 times a day. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted and a copy of this report provided to Assistant Executive Director. It was alleged staff failed to administer resident’s medication as prescribed . On 01/25/2023, LPA L. Fontanilla obtained and reviewed R1’s Medication Administration Record (MAR) for 2019-2020 and Centrally Stored Medication and Destruction Record (CSMDR). R1 had an order for Donepezil (Aricept) 10 mg 1 tablet by mouth daily in the morning and ½ tablet (25mg) by mouth after lunch. A review of R1’s MAR for 5/23/2021-6/22/2021 shows an encircled initial of the staff person giving medication from 5/30/2021 till 6/22/2021. Upon verification made by LPA L. Fontanilla with Robert Roby, the code facility uses if a resident refuses to take medication is the staff person’s initial with a circle around it. Based on records reviewed, R1 did not get Donepezil from 5/20/2021-6/22/2021. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted. Appeal Rights and a copy of this report provided to Assistant Executive Director.