complaint·May 20, 2024

It is alleged that R1 was admitted to facility on 4/19/2024 and required insulin and that it was not ordered by facility until 05/14/2024. LPA interviewed eight (8) residents and seven (7) of (8) residents could not collaborate the allegation. LPA interviewed five (5) staff and three (3) of five (5) staff stated they did not know because medications are not within their scope of work. S1 stated the medication was ordered on 4/19/2024 and they were waiting on doctors orders. No documentation was provide to support statement. One (1) staff stated that R1 medication was not ordered until 05/14/2024 and could not explain why. LPA reviewed R1 doctor's orders and the order form shows that the medication was ordered on 05/14/24 with a start date of 05/15/2024. The resident went with out medication for 25 days. Allegation: Staff did not assist resident to perform their glucose testing. It is alleged that facility did not provide resident with glucose meter until 25 days from admission. The investigation revealed: Review of documentation and medical records indicate that resident was admitted to facility on 04/19/2024 and resident arrived without a glucose meter. Resident's glucose meter arrived the same day (05/15/2024) as the medication according to S1. Facility failed to assist resident in testing R1 glucose for 25 days. Based on record review, and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . Deficiency is cited according to California Code of Regulations, Title 22. See LIC 9099D. Exit interview was conducted with Kathleen McDonald, Wellness Director A copy of the report and appeal rights were issued. The investigation revealed: LPA interviewed five (5) staff and five (5) of five (5) staff denied the allegation. LPA interviewed eight (8) residents and seven (7) of eight (8)residents could not collaborate the allegations. One resident stated that he is not aware he could ask for more food. LPA interviewed five (5) staff and five (5) of (5) staff denied the allegation. All staff stated that residents can eat as much as they like and just have to ask for more food if they desire more. LPA was present during the lunch hour and observed the food served to be plentiful and nutritious. Plates were removed after residents had finished their meals and many if not most plates had uneaten food. There is not enough evidence to substantiate this allegation. Allegation: Staff are not meeting resident’s bathing needs. It is alleged that residents are not assisted with bathing needs. LPA interviewed eight (8) residents and seven (7) of eight (8) residents could not collaborate the allegations. R1 stated R1 had sponge bath 3 days ago. LPA interviewed five (5) staff and five (5) of (5) staff denied the allegation. Staff stated that residents are assisted with bathing 2 times per week. There is not enough evidence to substantiate this allegation. Allegation: Staff made inappropriate comment to resident. It is alleged that unknown staff told resident "you're nasty" LPA interviewed eight (8) residents and eight (8) of eight (8) residents could not collaborate the allegations. All residents stated staff are respectful and considerate towards them. LPA interviewed five (5) staff and five (5) of (5) staff denied the allegation. Staff stated they are always respectful towards residents. There is not enough evidence to substantiate this allegation. Based on interviews, and observations conducted, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and copy of report provided to Wellness Director, Kathleen McDonald