complaint·August 12, 2022

LPA reviewed the department's database and confirmed facility reported several COVID cases in July and August of 2020. However, the facility did not report that 3 residents were diagnosed with scabies in August 2020. Based on the information obtained, the allegation is substantiated. Based on records reviewed, the preponderance of evidence standard has been met, therefore the allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview held. A copy of the report and appeal rights were provided. Staff interviewed denied ever seeing staff be rough with residents and denied any abuse. LPA obtained pictures of R1’s bruising. The bruising appears as light red in color on the upper lip, left cheek bone, left side of forehead and elbow. R1 was unavailable to be interviewed and there were no other witnesses to the alleged incident. Hospice documents were reviewed and there were no concerns noted. Residents have severe dementia and therefore, were not interviewed. Based on the information obtained, the allegation is unsubstantiated. Allegation - Staff are not following resident's care plan. R1’s care plan was reviewed. Staff were interviewed and indicated all services were being provided to R1. R1 is unavailable to be interviewed as R1 was discharged from this facility in 2020. Hospice documents were reviewed and there were no concerns noted. Based on the information obtained, the allegation is unsubstantiated. Allegation - Resident(s) sustained multiple pressure injuries due to neglect. Staff interviewed denied that R1 had any pressure injuries. R1 is unavailable to be interviewed. R1’s file was reviewed which included care plan, hospice documentation, hospital notes, and nurses notes. There was no documentation that R1 had any pressure injuries. There was no documentation or witnesses to confirm that R1 had pressure injuries. Therefore, the allegation is unsubstantiated. Allegation - Untrained staff are assisting with medications. It’s alleged that in 2020 facility staff were not trained in medication assistance. Interviews conducted with staff did not corroborate the allegation. Staff files were reviewed, and they contained the required staff medication training. Medication records were reviewed and they did not corroborate the allegation. There was no evidence that staff was ever responsible for a medication error. Based on the information obtained, the allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview held. A copy of the report was provided.