complaint·July 20, 2021

Allegation: Facility staff failed to maintain complete resident records. It is alleged on 07/20/2021 than Facility staff failed to maintain complete resident records: Witness states that fire department was called to assist in lift of resident 1. Witness states that staff was not able to move resident and that staff did not have complete medical records. On 07/20/2021LPA Calderon interviewed S1 that stated to have no knowledge of any issues with resident 1 or that staff could not move or lift resident 1 out of his bed. S1 states that staff did not submit an Special Incident report for this complaint or that the fire department showed up to his facility. S1 did not know that the resident DNR was not signed and that records were not the same. Staff was not able to give medical information for R1 while being taken to the hospital. On 07/20/2021 LPA Calderon interviewed S2-S3 who both confirm that the medical records were not complete and the DNR was not signed at the time the fire department showed up. On 07/20/2021 LPA Calderon reviewed medical reports for R1, confirmed the records for R1 were incomplete during the time the fire department came out to assist R1. Allegation: Facility staff failed to meet the resident’s needs. Witness states that fire department was called to assist in lift of resident 1. Witness states that staff was not able to move resident and that staff did not have complete medical records. On 07/20/2021LPA Calderon interviewed S1 that stated to have no knowledge of any issues with resident 1 or that staff could not move or lift resident 1 out of his bed. S1 states that staff did not submit an Special Incident report for this complaint or that the fire department showed up to his facility. S1 did not know that the resident DNR was not signed and that records were not the same. Staff was not able to give medical information for R1 while being taken to the hospital. On 07/20/2021 LPA Calderon interviewed S2-S3 who both confirm that the medical records were not complete and the DNR was not signed at the time the fire department showed up. On 07/20/2021 LPA Calderon reviewed medical reports for R1, confirmed the records for R1 were incomplete during the time the fire department came out to assist R1. Based on interviews conducted the facility staff and Administrator were not fully aware of R1 needs. The facility staff needed assistance from the fire department to transfer R1 and were unable to provide much information to the fire department. Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. A face to face exit interview was conducted with Administrator Stephen Gradney, and a hard copy was provided by hand for record