complaint·June 30, 2023

Allegation: Questionable Death Investigation Finding: Unsubstantiated Continuation from page 1 R1’s chief complaint was cardiopulmonary arrest. R1 was pronounced deceased at the hospital approximately 1425 hours on 08/06/22. Review of R1’s Death Certificate show cause of death was Cardiovascular Disease. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that resident’s death was questionable due to neglect/lack of supervision by staff is unsubstantiated. Allegation: Staff did not ensure that resident was adequately fed Investigation Finding: Unsubstantiated During investigation, staff (ADM) stated that R1 was a very picky eater and always ate breakfast daily. ADM stated R1 did not want to eat lunch and dinner at the facility since his admittance on 06/01/22. ADM stated she notified R1’s authorized representative (POA) about R1’s refusal to eat lunch and dinner. ADM stated staff offered him protein drinks (Boost) which he often refused. Review of weekly meal plans and random interviews with residents (R2, R3, R4) confirm they are fed three meals a day plus snacks by staff with a variety of meats, fruits and drinks. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff did not ensure that resident was adequately fed is unsubstantiated. Allegation: Staff prevented residents from having visitors Investigation Finding: Unsubstantiated During investigation, staff (ADM, S1) confirmed with LPA that residents were allowed to be visited at the facility. Staff, residents and visitors were screened at the front entrance for COVID infection control. ADM stated they encouraged residents’ families and visitors to make an appointment prior to the visit. Review of visitors logs show staff allowed visits by family, friends and other agencies at the facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff prevented residents from having visitors is unsubstantiated. Allegation: Staff did not ensure that residents grooming needs were met Investigation Finding: Unsubstantiated During investigation, staff (ADM, S1) stated that resident (R1) was showered and groomed twice a week (Tuesdays & Saturdays PM) by staff. Review of weekly shower schedule show residents’ shower frequency each week. LPA also interviewed random residents (R2, R3, R4) who confirmed that staff assisted them with their activities of daily living (bathing, grooming, dressing, toileting). Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff did not ensure that residents grooming needs were met is unsubstantiated. Allegation: Facility staff does not answer the telephone Investigation Finding: Unsubstantiated During investigation, LPA observed staff (ADM, S1) answered the facility phone when called on 08/19/22, 8/23/22 and 09/01/22. ADM stated the facility has a general phone number (925-732-7364) given for residents’ families/authorized representatives (POAs) to call and leave a message for staff to return call. ADM also stated they have a second phone line (925-303-2978) available for residents and families to use when necessary. ADM stated the fax number (925-732-7196) at the facility is a separate number from both phone lines and is not connected to any of the phone lines. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff does not answer the telephone is unsubstantiated. Exit Interview conducted and a copy of this report provided. Allegation: Staff did not maintain a medication log for residents Investigation Finding: Unfounded During investigation, LPA observed facility staff maintain Centrally Stored medication logs and medication administration records on residents. LPA reviewed copies of resident’s (R1) Centrally Stored medication logs and medication administration records with prescription dates filled by local pharmacy from 04/05/22 to 06/15/23. LPA also reviewed random residents’ (R2, R3, R4) prescribed medication records during visit. This department had investigated the complaint alleging that staff did not maintain a medication log for residents. We have found that the complaint was unfounded, meaning that the allegation was without reasonable basis. Allegation: Staff overmedicated resident Investigation Finding: Unfounded During investigation, LPA reviewed resident’s (R1) Centrally stored medication logs and medication administration records dated 04/05/22, 06/10/22, 06/15/22, 06/21/22, 06/23/22 which showed R1 was not prescribed or administered any morphine by staff while at the facility. Staff (ADM, S1) stated they administered prescribed medications as ordered by the residents’ primary care physicians. Staff (ADM) stated R1 was not on hospice care and was not prescribed morphine by his doctor. This department had investigated the complaint alleging that staff overmedicated R1. We have found that the complaint was unfounded, meaning that the allegation was without reasonable basis. Exit Interview conducted and a copy of this report provided.