complaint·October 25, 2023

Allegation: Staff mismanaged resident’s medication Investigation Finding: Substantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of R1’s incident report dated 04/25/22 showed missed administration of R1’s prescribed medications from 03/17/22 until 04/28/22 by facility staff. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff mismanaged resident’s medication was found to be substantiated. Allegation: Staff did not order refills in a timely manner Investigation Finding: Substantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of R1’s medical records showed that staff did not order timely refills of R1’s medications due to mismanagement of prescribed medications from 03/17/22 until 04/28/22. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff did not order refills in a timely manner was found to be substantiated. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights and copy of report provided. Allegation: Resident lost severe weight while in care Investigation Finding: Unsubstantiated During investigation, the department reviewed resident’s admission agreement which showed resident (R1) was first admitted at the facility under hospice care on 01/28/22. Hospice records showed R1 was on a regular diet and able to feed herself with minimal assistance from staff. Review of hospital discharge report dated 02/24/22 showed R1’s weight at 124 lbs. with a diagnosis of Alzheimer’s dementia with sundowning behaviors. New medications were ordered. On 02/16/22, R1’ s primary care physician (PCP) ordered a new prescription of Senna for R1’s constipation. On 03/14/22, R1’s PCP also prescribed Ensure nutritional shakes to be taken twice a day if she does not finish her meals. On 04/05/22, staff (S1) notified R1’ s primary care physician (PCP) that R1’s weight was at 126 lbs the last week of March and now weighed 116 lbs. Staff sent R1 to the hospital for treatment and evaluation of weight loss. Lab work was completed on 04/18/22 and on 4/19/22, R1’s PCP ordered staff to discontinue senna medication and continue calcium supplements. Staff stated that despite their efforts in encouraging R1 to eat and take her nutritional shakes, she continued to lose weight. R1 weighed 109 lbs when she left the facility on 06/13/22. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that resident lost severe weight while in care and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that resident lost severe weight while in care is unsubstantiated. Continued on next page, LIC 9099-C pg3 Allegation: Resident sustained a fall while in care Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of R1’s narrative charting showed she had an unwitnessed fall on 05/25/22. Staff assessed R1, called 911, sent her to the hospital for evaluation & treatment and notified authorized representative (POA)/ primary care physician (PCP) of the incident on 05/25/22. R1 was treated and returned back to the facility the same day with new medication orders. LPA observed staff assisted R1 in timely getting medical treatment and monitored R1 while in care. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that resident sustained a fall while in care and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that resident sustained a fall while in care is unsubstantiated. Allegation: Resident sustained UTI’s while in care Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of hospital discharge record dated 02/28/22 showed R1 was diagnosed with acute UTI along with dementia with behavioral disturbance and hospital issued new medications for treatment. Staff administered R1’s antibiotics for 7 days until her UTI was cleared. LPA observed no other episodes of UTI were reported during her stay at the facility. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that resident sustained UTI’s while in care and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that resident sustained UTI’s while in care is unsubstantiated. Continued on next page, LIC 9099-C pg4 Allegation: Resident was dehydrated while in care Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of R1’s physician’s orders dated 03/14/22 and 04/20/22, showed prescribed Ensure Liquid Vanilla shakes were ordered for R1 to take twice daily as needed if R1 does not finish her lunch and dinner meals. Staff stated that despite their efforts in encouraging R1 to eat and take her nutritional shakes, she continued to lose weight. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that resident was dehydrated while in care and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that resident was dehydrated while in care is unsubstantiated. Allegation: Insufficient staffing to meet residents’ needs Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of personnel records showed the facility had sufficient staffing including third party agency staff available on scheduled AM, PM and NOC shifts to provide care and supervision to residents in care. LPA interviewed residents (R2, R3) who stated that staff met their needs. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that there is insufficient staffing to meet residents’ needs and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that there is insufficient staffing to meet residents’ needs is unsubstantiated Exit interview conducted and a copy of this report provided.