complaint·July 21, 2023

(R7-R11). LPA attempted to interview R11, however, R11 is no longer a resident of the facility as of 05/03/2023. Allegations: Staff verbally abused resident while in care. Staff failed to treat resident with dignity and respect. It was reported that S1 verbally abused R11 by screaming at resident and telling resident to “Shut up”. A recording of incident was provided to Executive Director Michael Forsgern and S1 was terminated. During interview with Executive Director Michael Forsgern it was stated that the reason for S1 being terminated was because of this incident. During interviews with R1-R12, 10 out of 12 residents stated that they have never been verbally abused by staff, have not witnessed this with other residents and feel they are treated with dignity and respect. Residents also stated that they are able to use their own linens and blankets with no issues, 4 of the 5 residents interviewed today state they use their own linens. Based on LPAs observations, interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. interviews with Executive Director Michael Forsgern, Staff # 2-4 (S2-S4) and Resident # 7-12 (R7-R11). LPA attempted to interview R11, however, R11 is no longer a resident of the facility as of 05/03/2023. The investigation revealed the following: Allegation: Staff failed to meet resident’s medical needs. It was reported that the facility did not provide a good care to wound for R11. Record review of R11, interviews with Executive Director Michael Forsgern and S2-S4, and review of Skin Evaluation Guidelines it was revealed that facility does evaluations on wounds and skin breakdown upon admission and while assisting residents with their Assistance of Daily Living (ADL), if wound is observed resident’s primary physician is contacted, wound care/treatment would be provided by Home Health or by hospital staff. Upon admission 4/26/23 resident had completed treatment for wound care and was hospitalized by 5/3/23 for wound care and never returned to facility. During interviews conducted with R1-R12, 11 out of 12 residents disagree with the above allegation and stated the facility meets their medical needs. Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegation. 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 is UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.