complaint·February 6, 2025

The investigation revealed the following: Regarding Allegation #1 : Staff did not meet resident’s showering needs. It is being alleged that staff did not provide showers to residents. Record reviews indicate the following: R11’s Physician Report date 8/29/2023 indicates that R11 is able bathe self. The facilities shower logs for November 2023 indicates that R11 was reminded every Tuesdays and Fridays to take a shower. Interviews indicate the following: A1 indicates that all residents can take a shower at any time. 7 out of 7 staff indicate that R11 could take a shower with no assistance from staff, and that the facility keeps a shower log for those residents that refuse or forget to take a shower weekly. 10 out of 11 residents indicate that they can take a shower when they want, and staff have never told resident not to take a shower. Regarding Allegation #2 : Staff did not seek resident timely medical attention. This complaint alleged that staff did not seek timely medical attention after being notified that R11 was sick on 10/30/2023. Record reviews indicate: The facility ’s Incident report dated 10/30/3023 indicates that R11 was not feeling good, and staff assessed R11’s condition and their blood pressure was noted as regular. Staff requested cough medication and called R11’s doctor but there was no answer. The Incident report dated 10/31/2023 indicates that R11 had a cough, chest pain, and was asked R11 wanted to be taken to the hospital but R11 refused to be taken to the hospital, staff was to follow up with R11 and R11 family. Incident report date11/02/2023 indicates that R11 was found by staff unresponsive, CPR was done, 911 was called and R11 was transported to the hospital. Interviews indicate the following: A1 indicated that on 11/2/2023, S2 called A1 to R11’s room and A1 performed CPR on R11, staff moved R11 from the bed to the floor where A1 continued CPR on R11, and that 911 was called and A1 was able to find a pulse when the fire department arrived. A1 indicates that R11 was transported to St. Mary Hospital. S2 indicates that on 11/02/2023 S2 found R11 unresponsive in R11 bed. S2 indicates S2 started CPR on R11 and called 911. S2 indicates that S2 called A1 who arrived, continued CPR and A1 found a pulse. S2 indicates that R11 was transported to the hospital for evaluation. CCLD staff conducted an interview with R1-R10. 10 out of 10 residents indicate that when residents need medical attention staff provides timely medical services. Regarding Allegation #3 : Staff did not ensure security of resident’s personal belongings. This complaint alleged that staff did not secure R11’s purse. Record reviews indicate the following: R11’s personal property inventory log (dated 09/28/2023) indicated that there were 12 items noted for R11 personal belongings. This record indicates that R11 was admitted to the facility without a purse. There was no documented poof of stolen or lost property from R11 room. Interviews indicate the following: A1 indicates that on 11/14/2023 R11’s personal belongings were collected and stored for safety. A1 indicates that R11 purse was moved to the office, never was missing or stolen and that the resident purse was given back to resident family. A1 indicates that a property log is taken of exactly what the staff collects for the resident’s room and. CCLD staff conducted an interview with S7-S8. 7 out of 7 staff indicate that when R11 passed away staff collected the personal belongings of the resident, and a property log is kept for the facility records and that R11’s purse was never stolen or missing and was moved to the office for safety. 10 out of 10 residents indicate that none of their personal belongings have gone missing or been stolen while living at the facility and that staff make sure the facility is secure and safe. Regarding Allegation #4 : Staff explained circumstances at the time of resident’s death, different from what a doctor reported. This complaint alleged that the facility provided wrong information to a resident’s family regarding the resident’s medical emergency that happened on 11/02/2023, it is also being alleged that the resident passed away collapsing in the backyard at the facility. Record reviews indicate the following: Incident report dated 11/02/2023 indicates that R11 was observed non-responsive in their bedroom, was given CPR, 911 was called and was transported to Saint Mary’s Hospital. R11’s death certificate indicates that R11 passed away from Acute Myocardial Infarction, coronary artery disease at the hospital. Interviews indicate the following: A1 indicates that that A1 called the R11 family on 11/02/2023 and advised R11 family member that R11 had a heart attack and was transported to the hospital. S2 indicates that R11 was found unresponsive, and CPR was performed. S2 indicates that the front office contacted R11s’ family and advised of R11 medical status.10 out of 10 residents indicate that staff inform their families of any medical status or updates. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has NOT been met; therefore, the allegations of “staff did not meet residents showering needs”, “staff did not seek resident timely medical attention”, “staff did not ensure security of residents personal belongings”, “staff gave an explanation of circumstance at the time of residents death different from what a doctor reported” is found to be UNSUBSTANTIATED. An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Melissa Flores A1.