complaint·January 19, 2023

Allegation: Resident developed an infection while in care. Based on records review, on 3/2/2022 R1 was taken to urgent care, records review revealed that R1 was diagnosed of infection. Allegation: Medical treatment was not sought for resident in a timely manner. Based on interview and records review, on 2/24/2022 at 10:00AM staff informed facility nurse that R1 was sustained skin while staff transferring her from wheelchair to the shower. Basic first aid was rendered, and family was informed. However, R1 was not sent out to urgent care nor 9-1-1 not until around 3:00PM 02/24/2022. Allegation: Resident's medical records are not being maintained properly During the course of the investigation, records review revealed that facility failed to update a new physician’s report for R3, the last physician’s report was dated 04/2021. The preponderance of evidence has been met. Therefore, the allegations above are substantiated. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POCs) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided. Allegation: Resident developed a rash while in care Records review revealed that on 04/04/2022, staff observed redness on R1’s skin, family was notified and R1’s physician was notified. Nurses’ notes revealed that staff followed as needed doctor’s order to apply nystatin powder on the affected area. Allegation: Incidents involving resident are not being reported to their Resident Representative Based on interview and records review; staff notified R1’s family when there is a new observation or any change of condition. Allegation: Admissions agreement is not being adhered to During the investigation, RP did not specific deficiency that was called out regarding admission agreement. LPA conducted records review, based on records review admission agreement was completed according to regulations. Allegation: Resident's toileting needs are not being met while in care During the course of investigation, records review revealed that R1 had toileting assistance of taking her to the bathroom 2-3X while awake and at least 5x during night shift. Interview with staff revealed that residents who needs incontinence care is checked 3-4 times per shift on residents with incontinence care/toileting needs. However, when residents have a bowel movement or an accident, staff will change and clean residents right away. During LPA’s visit, LPA could not interview R1 since she no longer at the facility. Allegation: Medications are not being administered to resident according to their physician's orders. Based on records review, medication administration records (MAR) revealed that staff gave R1’s medication according to physician’s order. R1’s MAR revealed there was no miss medications and discontinued medication was stopped per doctor’s order. LPA attempted to interview R1 regarding this allegation however R1 no longer at the facility. Allegation: Insufficient staff LPA reviewed staff schedule for the facility, facility has Med Tech, support staff and other agency staffing available on schedule. Facility had sufficient staffing for all three (3) shifts. Residents were observed calm and comfortable in their surroundings. LPA conducted interview with staff and reported that facility and had no issues, staff also mentioned that is someone called and sick, management tries to ask assistance from assisted living department to provide assistance on the memory care unit. Based on interviews conducted and records reviewed, the preponderance of evidence standard has not been met, therefore the allegation is found to be UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove it did or did not occur. Exit interview conducted, appeal rights and copy of this report provided .