complaint·July 22, 2021

Staff are chemically restraining resident. During interview with Executive Director and records reviewed, it was determined that the Staff are chemically restraining resident to be unsubstantiated. After interview and record reviews, it was concluded that R1 was given all prescriptions as prescribed from the hospice physician. LPA reviewed R1’s MARS, observed that the Haloperidol 5mg was prescribed as a PRN and taken as needed. LPA reviewed records and R1 did not even receive the Haloperidol every day, only as needed. LPA reviewed MARS/Medication list and did not observe any errors, missed medications, and was all signed by staff. The preponderance of evidence standard has not been met. The allegation is unsubstantiated. Facility not following resident's hospice care plan. During interview with Executive Director and records reviewed, it was determined that the Facility not following resident's hospice care plan to be unsubstantiated. After interview and record reviews, it was concluded that the facility was following hospice care plan as requested from Enloe Hospice. R1 was given all prescriptions as prescribed from the hospice physician. R1 was being seen from a physician at the facility while on hospice. The preponderance of evidence standard has not been met. The allegation is unsubstantiated. Based on the information obtained, records reviewed, and interviews conducted, the above allegations are Unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are Unsubstantiated. An exit interview was conducted with the ED. There are no citations given at this time. Staff threw a glass of water in resident's face. During interview with Executive Director, and records reviewed, it was determined that Staff threw a glass of water in resident's face to be Substantiated. During interview and records reviewed it was concluded that S1 did throw water at R1. S1 admitted to throwing water at R1. S1 was terminated and never picked up her last check, the facility had to mail it to S1. The preponderance of evidence standard has been met. The allegation is Substantiated. Based on the evidence obtained, the preponderance of evidence standard has been met; therefore, the allegation is found to be Substantiated . California Code of Regulations (Title 22) is being cited on the attached LIC 9099D. Appeal rights are provided, and a closure interview was conducted.