complaint·November 21, 2024

The investigation revealed the following. Regarding Allegations : Facility did not maintain liability insurance – It is alleged the facility did not maintain liability insurance during 2022 and does not have current liability insurance. During record review, LPA Ramirez observed liability insurance coverage from 03/09/2022 through 03/09/2025. LPA Ramirez called insurance broker to verify liability insurance is currently maintained and verified coverage limits. 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 UNSUBSTANTIATED . Facility overmedicated resident- It is alleged R1 was overmedicated while receiving care at the facility. R1 was admitted to the facility on 12/01/2022 and was discharged on 12/29/2022. R1 began hospice care on 12/01/2022. During record review, LPA Ramirez reviewed R1’s MAR for the month of December of 2022. LPA Ramirez did not observe any notes on MAR, or documentation to collaborate this allegation. Review of hospice progress note did not collaborate this allegation. Five (5) out of the five (5) staff interviewed deny this allegation. R1 is no longer at the facility and unable to be interviewed. LPA Ramirez made several attempts to contact R1’s responsible party, but as of 11/21/2024, LPA Ramirez has not received a call back. Two (2) out of the two (2) residents interviewed deny this allegation. Pomona Valley Hospital Medical Center medical report dated 12/19/2022, did not collaborate this 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 UNSUBSTANTIATED . Facility improperly restrained resident- It is alleged facility staff improperly restrained resident and wrapped in a baby highchair. Allegedly, this caused R1’s knee to remain bent and unable to walk anymore. R1 was admitted to the facility on 12/01/2022 and was discharged on 12/29/2022. R1 began hospice care on 12/01/2022. During facility tour, LPA Ramirez observed several residents sitting in wheelchairs, recliners, chairs, and couch. LPA Ramirez did not observe a baby highchair at the facility. LPA Ramirez did not observe restraints near chairs, wheelchairs, or recliner. Review of R1’s hospice progress notes and medical notes from Pomona Valley Medical Center, did not collaborate this allegation. Five (5) out of the five (5) staff interviewed deny this allegation. R1 is no longer at the facility and unable to be interviewed. LPA Ramirez made several attempts to contact R1’s responsible party, but as of 11/21/2024, LPA Ramirez has not received a call back. Two (2) out of the two (2) residents interviewed deny this 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 UNSUBSTANTIATED . See 9099-C for continued report. Facility staff neglect resulted in resident falling and sustaining injuries- It is alleged R1 fell and became injured because of staff neglect. R1 was admitted to the facility on 12/01/2022 and was discharged on 12/29/2022. R1 began hospice care on 12/01/2022. On 12/17/2024, R1 was observed sitting in his wheelchair; in the facility living room area. R1 fell/slid out of his wheelchair and began to complain of a headache. Hospice and R1’s responsible party was notified. Facility staff called 911. R1 was admitted to Pomona Valley Medical Center on 12/17/2024 and cleared for discharge on 12/19/2024 back to the facility. Per Pomona Valley Medical Center report, R1’s responsible party agreed to discharge R1 back to the facility and continue hospice care. According to Pomona Valley Medical Center report, R1 was deemed stable on 12/19/2022 and cleared by Neurosurgery to be discharged. Five (5) out of the five (5) staff interviewed deny this allegation. R1 is no longer at the facility and unable to be interviewed. LPA Ramirez made several attempts to contact R1’s responsible party, but as of 11/21/2024, LPA Ramirez has not received a call back. Two (2) out of the two (2) residents interviewed deny this allegation. Although, R1 did suffer a fall and did sustain a minor injury, LPA Ramirez did not observe documentation or interviews to suggest this was as a direct result from staff neglect. 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 UNSUBSTANTIATED . Facility was not feeding resident- It is alleged R1 was not being fed and R1’s responsible party had to bring R1 food. R1 was admitted to the facility on 12/01/2022 and was discharged on 12/29/2022. R1 began hospice care on 12/01/2022. Review of R1’s Medical Assessment dated 11/30/2022, recorded R1’s weight as 125lbs. Per Pomona Valley Medical Center report dated 12/19/2022, R1’s weight was recorded as 54.9 kg (121lbs) on 12/18/2022. Five (5) out of the five (5) staff interviewed deny this allegation. R1 is no longer at the facility and unable to be interviewed. LPA Ramirez made several attempts to contact R1’s responsible party, but as of 11/21/2024, LPA Ramirez has not received a call back. Two (2) out of the two (2) residents interviewed deny this allegation. During facility tour, LPA Ramirez observed staff serving lunch and assisting residents with their meals. LPA Ramirez sufficient food supply in kitchen. 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 UNSUBSTANTIATED . No violations were observed during this investigation. Exit interview was conducted. A copy of this report was provided.