complaint·October 13, 2022

resident (via telephone), but to no avail. LPA/RA Ceniceros reviewed pertinent documents: Admissions Agreement (dated 03/05/20), Emergency I.D. & Information (03/05/20), Physician’s Report (dated 02/21/20), Pre-placement Appraisal Information (dated 03/05/20) for Resident #1; including facility staff roster and residents' roster; SIR (dated 02/19/21), Eight-Hour Medication Training (dated 02/16/22), Personal Rights training (dated 06/22/21), and Staff In-Service Training (dated 12/21/21). Regarding Allegation #1 : this investigation revealed based on interviews conducted corroborated that residents in care have not been spoken to inappropriately by facility staff. Staff Members have not received complaints from residents in care and/or their responsible person(s) regarding same. A review of an SIR (dated 02/19/2) documented an incident (Aggressive Act/Self & Aggressive Act/Staff) that occurred involving Resident #1 towards Staff #4 (Med Tech); whereby, Resident #1 had become aggressive towards Staff #4. Resident #1 had been drinking alcohol at the facility which was found in Resident #1's room. Resident #1 became increasingly aggressive and began yelling obscenities (i.e., racial slurs at staff, EMTs, and police officers). Resident #1 was transported to the hospital for further evaluation. LPA/RA Ceniceros also reviewed facility's Personal Rights training which was conducted on 06/22/21. Based on the evidence gathered and interviews conducted and records reviewed, 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 of PERSONAL RIGHTS: Staff inappropriately speak to residents in care is found to be UNSUBSTANTIATED. Regarding Allegation #2 : this investigation revealed based on interviews conducted corroborated that residents in care are being administered their medications by the med techs. LPA/RA Ceniceros toured the facility's medication room and observed the computerized "QUICK-MAR" system utilized for the residents' medication administration records and residents' medications stored in a secured cart. LPA/RA Ceniceros also reviewed the facility's last 8-Hour Medication Training that was conducted on 02/16/22 by a pharmacy's nurse consultant. Based on the evidence gathered and interviews conducted and records reviewed, 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 of MEDICATIONS: Residents are not being provided their medications as prescribed is found to be UNSUBSTANTIATED. Regarding Allegation #3 : this investigation revealed based on interviews conducted corroborated that facility staff have not left incontinent residents in soiled diapers for long periods of time. Facility staff members had not received a complaint from residents in care and/or their responsible person(s) regarding same. A review of Resident #1's " Physician's Report " (dated 02/21/20) documented under " Physical Health Status " that the resident does not have bowel impairment or bladder impairment. A review of Resident #1's " Pre- placement Appraisal Information " (dated 03/05/20) documented that the resident is incontinent at times and wears pull-ups for precaution. A review of the facility's " Staff In-Service " training on the topic of "Checking all residents every two (2) hours as needed" was conducted on 12/21/21. Based on the evidence gathered and interviews conducted and records reviewed, 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 of NEGLECT/LACK OF SUPERVISION: Residents are being left in soiled diapers for long periods of time is found to be UNSUBSTANTIATED. An exit interview was conducted and a copy of the Complaint Report provided to Staff #1: Marili Barajas, Office Manager.