complaint·June 26, 2024

Per record review, R1’s admission agreement, dated and signed 01/02/2020 stated that resident requires or desires assistance in meeting medical and dental needs. Interview conducted with the Administrator from another complaint relating to R1, dated 03/04/2022 stated that R1 went to doctor’s appointments by themselves and R1 did not communicate with facility staff regarding R1’s doctor’s appointments or aftercare. Administrator stated that R1 was independent and dealt with medical care by themselves. However, it was revealed during a record review that R1 had a California Advance Health Care Directive and a Power of Attorney (POA) and in the document R1 stated that R1 wants R1’s agent to make health care decisions now even though R1 currently had the mental capacity to make own health care decisions; document signed and dated 02/25/2016. Interview conducted with the Administrator from another complaint relating to R1, dated 03/04/2022 stated that the facility did not have a copy of R1’s POA paperwork stating that R1 had a medical POA. Additionally, R1 was enrolled in the Assisted Living Waiver Program (ALW) and it was documented on R1’s Individual Service Plan (ISP) dated 06/26/2020 that R1 does not understand all medical appointment necessary to manage R1’s multiple medical diagnoses. The ISP continues stating, “Under medical supervision, participant’s active diagnosis will remain under control with no disease progression. RCFE and participant will work together to identify all medical specialists required to address all active diagnoses. RCFE will assist participant with scheduling all follow up appointments and lab work ordered by MD.” Although facility staff believed R1 was independent and was capable of caring for R1’s own medical care, R1 did need assistance with arranging medical care and the facility staff should have communicated with R1’s POA/ responsible person regarding R1’s medical care and needs. Furthermore, facility staff should have maintained proper paperwork that was essential to observing R1 and ensuring that R1’s medical needs would be met. Based on record review and interviews, the preponderance of evidence standard has been met, therefore the above allegations are deemed Substantiated. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit (See 9099-D). Exit interview conducted. A copy of the report and appeal rights were provided. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Regarding the allegation: Conduct inimical. It was alleged that facility staff purposely ignored R1’s medical care and needs. Although facility staff did not have proper documents such as California Advance Health Care Directive and a Power of Attorney (POA) for R1 in order to provide proper care and supervision, the LPA could not determine that the facility staff purposely ignored R1’s medical care needs. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Regarding the allegation: Failure to report Covid-19 outbreak. It was alleged that the facility had a Coronavirus Disease 2019 (COVID-19) outbreak during November 2020 and failed to report to appropriate agencies. The complainant alleged that the facility was on lock down during the month of November 2020. Record review revealed that COVID-19 was reported to Community Care Licensing on December 10, 2020. It was reported that the initial COVID-19 test were conducted on December 6, 2020, and results came in on December 8, 2020. There was no further documentation of an outbreak prior to December 2020. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was provided.