complaint·May 18, 2025

Regarding allegations - Staff did not ensure resident had their oxygen when out of room and Staff did not safeguard resident's personal belongings: Information was received that Resident #1 (R1) was not on continuous oxygen from approximately 01/09/2025 – 01/17/2025. According to the reporting party the facility evacuated on 01/09/2025 due to the Kenneth fire and R1’s portable oxygen was lost. Staff did not ensure R1 was on continuous oxygen. R1 went to a hair appointment without a supply of oxygen. It was confirmed through interviews and records review that there is an order on file from R1’s physician that R1 requires continues (24 hours) oxygen use. Staff interviewed confirmed that R1’s portable oxygen cord was lost during the evacuation period. Staff stated that R1 was provide with a concentrator which was used in room and when R1 would go down for meals. R1’s facility records reviewed with staff revealed that R1’s assessments/care plan did not indicate that R1 is required 24-hour oxygen use. Staff could not confirm that R1 was monitored and ensured that when R1 left the room or went out of the facility was with oxygen. Based on the information obtained through record review and interviews; the allegations “Staff did not ensure resident had their oxygen when out of room and Staff did not safeguard resident's personal belongings”, is deemed substantiated at this time. On 02/19/2025, during a subsequent complaint visit for another complaint, LPA Chochian reviewed medication records and interviewed additional staff. Following is summary of the investigation: On 01/24/2025, From approximately 11am- 1:45pm LPA and Mrs. Alvarado toured the facility common areas and resident rooms. Interviews were conducted during the tour with 6 (six) randomly selected residents and 2 (two) other potential witnesses. Also during the tour LPA visited the medication room and reviewed random sample centrally stored medication records with staff. Residents interviewed reported no issues or concerns with receiving care services from staff. Resident expressed being satisfied with staff providing care and medication service. Resident #1 was out of the building during LPA’s visit therefore was unable to be interviewed at that time. LPA was able to communicate with resident #1 on 05/09/2025 however resident was not able to provide much information due to decline in health. Resident did express being satisfied with the staff at the facility. Resident was unable to recall the alleged incident related to medications being left in resident’s room. LPA conducted a sample review of the centrally stored medication records for the month of January 2025 and found no discrepancies at the time. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegations “Staff are not checking on resident” and “Staff are mismanaging resident’s medication” is deemed unsubstantiated at this time. Exit interview held and copy of report provided.