complaint·June 1, 2023

The investigation revealed the following: Regarding the allegation: "Staff did not notify Responsible Party of resident's change in condition.” R1’s Physician's Report dated 03/04/2021 indicated that R1 had "mild memory loss" and "depression", Staff interviews and the facility’s internal records indicate unusual behavioral changes in R1 such as being aggressive towards other residents and imposing their religious beliefs towards staff and residents on 05/05/23, 05/08/23, 05/15/23 and 05/16/23, LPA did not observe any evidence that the residents responsible party were contacted during, or immediately after, said incidents. Based on staff interviews, record reviews and observations conducted during this inspection, there is sufficient information to verify the allegation "Staff did not notify Responsible Party of resident's change in condition.". Therefore, the allegation is Substantiated. Regarding the allegation: “Staff did not seek medical attention for resident in a timely manner.” LPA interviews indicate that, on 05/17/23, witness W1 initiated a tele-health appointment for R1. As a result, R1 was ordered to be sent to the ER by their primary care physician, where R1 was diagnosed having a "manic-episode". Staff interviews and the facility’s internal records indicate unusual behavioral changes in R1 such as being aggressive towards other residents and imposing their religious beliefs towards staff and residents on 05/05/23, 05/08/23, 05/15/23 and 05/16/23. LPA did not observe any evidence that the facility sought medical attention for the resident, R1. Based on interviews and observations, there is a sufficient information to verify the allegation “Staff did not seek medical attention for resident in a timely manner.” Therefore, the allegation is Substantiated. Deficiencies under Title 22 regulations have been cited, see LIC9099D. An exit interview was conducted and plans of corrections were developed with Wilfred Guerrero. A copy of this report and appeal rights have been provided.