complaint·August 29, 2023

The investigation revealed the following: In regards to the allegation " Facility did not meet resident's needs while in care", it is alleged that "Staff called emergency medical services because of R1’s medical condition and medical staff determined that R1’s condition was poor and appeared neglected." A total of six (6) staff were interviewed and all denied the allegation and stated that staff have been providing care and assistance to R1. R1 resided at the facility from July 3, 2021, until Aug 5, 2022, and needed total assistance with mobility and transfers. S1 stated that R1’s health condition was declining since mid-June of 2022. On 7/20/22, S2 stated that R1 may have suffered a suspected “mini stroke” or TIA but did not call 911 because V1 discouraged her. S2 indicated that R1’s pressure injury opened on 08/02/22 an informed V1. However facility staff did not seek medical attention for R1 at this time even though R1’s condition was declining. S1 informed V1 that R1 may need to go on hospice for more care. On 8/05/2022, tele health appointment with R1’s primary physician with regards to hospice care was conducted and follow up evaluation was scheduled for Sat. 8/6/22 or Sun. 8/7/22. However, on 8/05/2022, S2 noticed that R1 had a temperature and had difficulty breathing. S2 stated that she called and asked V1’s permission to call 911 for R1 who hesitated at first but later agreed. S2 stated that Paramedics and Fire fighters took R1 to the Hospital. 3 days had passed before facility staff seeked medical attention for R1. During interviews, facility staff indicated that they would seek approval from V1 before medical attention for R1 was obtained. LPA’s review of the progress notes indicated that V1 was in regular communication with the facility. 5 out of 5 residents interviewed all denied the allegation and stated that staff take care of their needs. LPA was not able to interview R1 because she never returned to the facility after hospitalization on 8/05/2022 and later passed away in January 2023. Based on LPA’s observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . Exit interview was conducted and deficiency was cited. A copy of this report was provided to the Administrator Flordeliza Sasada along with the Appeals Rights.