complaint·October 25, 2023

Allegation: Staff overmedicated resident Investigation Finding: Substantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of incident report dated 08/01/22 showed R1’s medications were not being administered as prescribed from 02/23/22 until 05/13/22. A signed and dated medication list from R1’s primary care physician (PCP) indicated R1 should only be taking 2 medications. 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 overmedicated resident was found to be substantiated. Allegation: Staff did not follow doctor’s orders Investigation Finding: Substantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. LPA interviewed staff (ED) who confirmed that medication errors occurred due to staff failing to contact R1’s authorized representative (POA) and primary care physician (PCP) in clarifying a change in the medication administration records which were accepted without proper verification of physician’s orders. 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 follow doctor’s orders 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: Staff did not safeguard resident’s property Investigation Finding: Unsubstantiated During investigation, the department reviewed R1’s signed admission agreement dated 01/22/20 which showed that the facility is not responsible for the loss or theft of valuables from a resident’s apartment. Review of authorized representative’s (POA) letter with facility staff dated 08/31/22 showed she reduced the monthly bill for the lost bedding she replaced in June 2022. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff did not safeguard resident’s property 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 staff did not safeguard resident’s property is unsubstantiated. Allegation: Staff did not notify resident’s POA of change in resident’s condition Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of R1’s incident reports dated 03/08/22 and 07/09/22 showed staff notified R1’s authorized representative (POA) and primary care physician (PCP) of incidents involving R1 being unresponsive and sent to the hospital due to a change in condition. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff did not notify resident’s POA of change in resident’s condition 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 staff did not notify resident’s POA of change in resident’s condition is unsubstantiated. Continued on next page, LIC 9099-C pg3 Allegation: Staff did not notify POA of incidents Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of R1’s incident reports from 03/04/2020 until 08/01/22 showed staff notified R1’s family and primary care physician of incidents involving aggressive behaviors towards other residents and staff, unwitnessed fall, 911/ER visits, change in condition and medication errors. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff did not notify POA of incidents 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 staff did not notify POA of incidents is unsubstantiated. Allegation: Staff did not respond to POA Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. LPA interviewed staff (ED, S1) who stated that they communicated with resident’s (R1) authorized representative (POA) frequently regarding R1’s level of care, billing, new and discontinued medications orders. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff did not respond to POA 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 staff did not respond to POA is unsubstantiated. Continued on next page, LIC 9099-C pg4 Allegation: Staff did not ensure resident’s hygiene care was met Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of R1’s needs and services records showed staff provided total assistance for R1’s hygiene care, grooming, dressing, toileting, ambulation and transfers. LPA interviewed staff who stated R1 would constantly refuse showers so they would give her a sponge bath instead upon refusal. Review of Incident report dated 06/29/22 showed staff was hit on the head by R1 while assisting her with a shower. Staff called for help because R1 started to swing at her again. Another staff took over and was able to complete R1’s dressing. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff did not ensure resident’s hygiene care was met 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 staff did not ensure resident’s hygiene care was met is unsubstantiated. Exit interview conducted and a copy of this report provided.