complaint·September 22, 2023

The investigation revealed the following: in regards to the allegation "Facility did not ensure that resident was adequately fed while in care", it is alleged that the resident had stopped eating and lost a lot of weight which led her family to call an ambulance to take her to a hospital over fears of malnutrition. During interviews with the residents, none of them corroborated the allegation that the facility does not ensure they are adequately fed. All of them indicated that they offer breakfast, lunch, dinner, and snacks to all the residents, and R8 indicated that they also accommodate her vegetarian diet as well and therefore believes they offer a good variety of food as well. During interviews with the staff members, none of them corroborated the allegation that residents are not adequately fed while in care. All staff explained that residents are fed breakfast lunch and dinner at the facility, and S2 along with S6 explained that if a resident is determined to be failing in death due to no longer eating, then they immediately report the issue to the resident's physician for further guidance. In regards to the allegation " Facility did not ensure that resident was adequately hydrated while in care ", it is alleged that once R1 was admitted into the hospital, it was determined by the doctors at the hospital through testing that the resident was suffering from extreme dehydration along with malnutrition. During interviews with the residents, none of them corroborated the allegation that residents are not adequately hydrated while in care. All residents interviewed indicated that water and juice is available for them at all hours of the day whenever they ask for it. During interviews with the residents, none of them corroborated the allegation that they do not ensure that residents are adequately hydrated. They all explained that water and juice is provided to the residents every day, and S4 explained that if a resident is displaying signs of failing to hydrate themselves, the facility makes sure to elevate the situation to the Med Techs and the resident's physician to determine the next course of action. 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 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 above allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided. Regarding the allegation " Facility did not seek resident timely medical attention ", it is alleged that R1's deteriorating health condition due to malnutrition and dehydration was not properly addressed by the staff of the facility, which forced her family to call an ambulance to take her to a local hospital. During interviews with the residents, seven (7) out of eleven (11) residents interviewed corroborated the allegation that they have not received appointments with doctors and specialists after they have asked for assistance in scheduling appointments, others have said delays in receiving medical care have forced them to admit themselves to the emergency room, and others explain that they are still waiting for medical care as they have not received a full physical since being admitted to the facility despite having health concerns. During interviews with the staff, none of them corroborated the allegation that the facility does not seek timely medical attention for the residents, however S6 did explain that R1 did not want to eat during their quarantine due to COVID and it was perhaps overlooked that R1's condition may have been declining at this time and did not seek medical attention for R1. The facility initially notified R1's family of the facility's concern that R1 had not been eating on 7/26/2022, and this report along with the family's concern that they had not had contact with R1 in the recent days led the family to call an ambulance and paramedics to take R1 to the hospital on 7/31/2022. R1 did not return to the facility after this hospitalization. Based on LPAs interviews conducted with the residents and staff, the preponderance of evidence standard has been met for the above allegation, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099D. Exit interview held and a copy of the report and appeal rights was provided to the administrator Logan Harrison.