complaint·June 18, 2024

Staff did not administer resident's medication – SUBSTANTIATED It was reported that a resident was hospitalized due to the facility not giving him his medication (Levothyroxine). LPA document review: MAR dated November and December 2023 do not include the medication Levothyroxine. Physician’s Reported dated 11/07/2023 includes the following information: SECONDARY DIAGNOSIS(ES): a. Treatment/medication (type and dosage)/equipment Hypothyroid, levothyroxine 17Smcg one PO dally. COO stated That med was missed. On the original orders it does have levothyroxine, I don’t see it on the MARS. It was determined that based on interviews and document review due to R1 not receiving his levothyroxine medication, his hyperthyroidism was untreated, and R1 was hospitalized and treated for severe hypothyroidism. This allegation is substantiated. This is a repeat violation, the same violation was cited on 03/19/2024 and 04/23/2024. Civil penalties are being assessed in the amount of $1,000.00 this date on the attached LIC421M for repeat violation within a 12 month period. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview conducted and a copy of the report was provided to COO Diania Bingham. Staff did not properly care for resident's wounds - UNSUBSTANTIATED It was reported that a resident had cuts on their body that were not being treated. Staff stated that R1 had some skin tears and bruises when he moved in, the med techs would bandage him if he was bleeding but “outside people” were providing wound care. COO stated When he got here from his previous facility, he had existing skin tears that he would pick at and they would reopen that’s what kept him chronic. He had skin tears on his legs and we sent him out to have them look at them and they sent him back to us. The VA was following the wounds on his legs. They kept his skin tears wrapped because he picks at them and doesn’t allow them to heal. The VA does it all, even if it (bandages) comes loose the VA comes in. It was determined that when R1 moved into the facility in January 2024 he had some bruises and skin tears. The VA was providing care for these wounds although the med tech would provide first aid if required. This allegation is unsubstantiated. Staff are not meeting resident's laundry needs - UNSUBSTANTIATED It was reported that a resident had no clean clothes. Staff stated that R1 was showered twice a week and his laundry was done on the same days. Staff always assisted R1 with changing clothes. When R1 moved into the facility he had a lot of shirts, underwear, and jeans but not a lot of pajama bottoms. COO stated that staff have been doing the resident’s laundry. They would encourage him to change his clothes. He was very self-determined and he would self-direct but staff would try to get him to change his clothes. It was determined that when R1 moved into the facility he had a lot of shirts, underwear, and jeans but not a lot of pajama bottoms. Staff were doing R1’s laundry twice a week. This allegation is unsubstantiated. Continued on LIC9099-C Staff are not providing a comfortable temperature for residents - UNSUBSTANTIATED LPA observed the thermostats to all be set at 78 degrees Fahrenheit. Staff interviews revealed that the temperature can vary but overall, the facility is kept at a comfortable temperature. COO stated the thermostat is set at 78 degrees all of them are in controlled environments. It was determined the thermostats are all set for 78 degrees which is a comfortable temperature. This allegation is unsubstantiated. Although the allegations may have happened or are 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. A copy of the report was provided to COO Diania Bingham.