complaint·March 21, 2023

Continued from 9099 LPA’s interview with Executive Director Lito Vitug, revealed that R1 used an orthopedic shoe with a thick sole, but they do not recall R1’s shoe ever being in disrepair. LPA’s interview with nine (9) staff revealed that all staff have never observed R1’s shoes in disrepair. LPA’s interview with representative revealed they did not have any additional information to provide regarding the shoe. Based on information gathered during this and previous visits, the department does not have sufficient evidence to determine that the sole of R1’s shoes was coming apart. Therefore, the allegation that Resident’s shoe was in disrepair has been deemed UNSUBSTANTIATED at this time. It was reported that staff did not provide medical care to resident, as it was alleged that the facility did not get an MRI or a CT scan as it was reportedly suggested by X-Ray technician. LPA records review of resident file and interview with Staff 1 (S1) along with Executive Director, revealed on December on 12/02/2020, at approximately 6pm, R1 reported to S1 they had sustained a fall earlier in the day. A health assessment was conducted with R1 and R1 did not complain of any pain or discomfort and declined to be admitted to the hospital. On 12/03/2020, X-Rays were conducted on R1 at the facility. Review further revealed that the X-Rays did not indicate there were any fractures, injuries or bruising and that further evaluation with either a CT or MRI scan was suggested if clinical concerns remained high. LPA’s records review and interviews with staff revealed R1 did not complain of any pain or discomfort in the days following when the alleged fall had occurred. Based on information gathered during this and previous visits, the department does not have sufficient evidence to determine that R1 required a MRI or CT scan. Therefore, the allegation that staff did not provide medical care to resident has been deemed UNSUBSTANTIATED at this time. It was reported that staff did not tell the authorized representative in resident’s change of condition, as it was alleged that facility never informed representative that R1 tested positive for COVID, had symptoms related to COVID and R1’s overall health had declined. LPA records review of residents file and interview with Vitug revealed, R1 received a PCR test on 11/30/2020. On 12/05/2020 the results indicated R1 tested negative for COVID. On 12/06/2020, R1’s representative relocated R1 from the facility to be cared for at their home. Interview and records review of resident’s file and hospital discharge records further revealed there were no change of conditions to R1’s overall health from 11/30/2020 when R1 was initially tested for COVID to 12/06/2020, when R1 was relocated from the facility. Continued from 9099-C On 12/13/2020, Vitug was informed by R1’s representative that R1 had been admitted into a local hospital and tested positive for COVID-19. On 12/21/2020, the representative of R1 requested that R1 be discharged back to the facility. Based on information gathered during this and previous visits the department does not have sufficient evidence to determine that facility never informed representative about R1’s change of condition, therefore the allegation that staff did not tell the authorized representative in resident’s change of condition has been deemed UNSUBSTANTIATED at this time. It was further reported that staff are not properly trained, as it was alleged that staff was not aware of R1’s incident regarding alleged fall. LPA interview with Vitug and R1’s representative revealed, on 12/05/2020, R1’s representative called the facility to inquire about R1’s alleged fall on 12/02/2020 and they initially spoke to Staff 2 (S2), who at that time, did not have any knowledge of incident involving R1. The initial call was then transferred to Administrator Lori McKay, how had knowledge of the incident. Interview with Vitug further revealed S2 was a part-time employee who had just began working with the facility a week prior. Records reviewed during the course of the investigation reflected that S2 had all of the required training for a new employee; however, was not aware of the alleged incident as S2 was new. Based on information gathered, the department does not have sufficient evidence to determine that the staff are not properly trained. Therefore, the above allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted copy of report issued. Continued from 9099-A LPA records review of resident file and interview with Staff 1 (S1) along with Executive Director, revealed on 12/02/2020, at approximately 6pm, R1 reported to S1 they had sustained a fall earlier in the day. A health assessment was conducted with R1 and R1 did not complain of any pain or discomfort and declined to be admitted to the hospital. R1 was not able to recall when or where they fell in their private room. Interview and records review further revealed R1’s primary care physician was immediately notified, but records did not indicate any call was made to R1’s authorized representative. LPA’s interview with R1’s representative and records review revealed the representative called the facility on 12/05/2020 to inquire about information they received from another family member, that R1 had sustained a fall. Based on information gathered during this and previous visits, the department has sufficient evidence to determine that the authorized representative was not notified after facility staff were made aware that R1 may have sustained an unwitnessed fall. Therefore, the allegation that staff did not notify authorized representative about resident’s unwitnessed fall has been SUBSTANTIATED at this time. Pursuant to the California Code of Regulations, Title 22, Division 6, Chapter 6, the deficiencies listed on 9099-D were confirmed and cited. Exit interview conducted and copy of report issued.