Complaint·July 14, 2023

Continued from LIC9099A On 04/29/2023, R1 communicated to Staff that they did not feel well and had leg pain. Review of Facility documentation and incident reports indicated that R1’ s Responsible Party was contacted and informed of R1’s condition on 04/29/2023. Report reviewed stated R1’s Responsible Party declined having 911 called for R1, and that they did not want emergency transport provided. This allegation is Unsubstantiated. There is an allegation that Staff did not observe change in resident’s condition. The Report states the following concerns: Staff did not observe R1’s wheezing and coughing, Staff did not observe R1’s stomach distention, and Staff did not observe a change in R1’s legs. Review of R1’s Progress notes showed that on 04/24/2023, Staff observed R1 to have a moist cough. Staff contacted R1’s Primary Care Physician on 04/25/2023 when it was observed that R1’s cough did not go away. On 04/26/2023, R1’s Physician ordered a test to be conducted and R1 was prescribed antibiotics. Documents reviewed indicated that Facility communicated with R1’s Responsible Party on 04/28/2023 when R1’s antibiotics arrived and when they received their first dose. Reporting Party stated that it was observed R1 had distension in their stomach on 04/29/2023. Review of R1’s Hospital Notes,dated 04/29/2023, stated that distension was observed. Notes continued to state that R1 denied having any abdominal pain when asked and that R1 had a bowel movement on 04/28/2023, and passed gas that morning prior to their hospital visit. Review of R1’s Bowel Movement Chart indicated that R1 had a bowel movement the morning of 04/27/2023 and again on 04/29/2023. Reporting Party stated that Staff did not observe a change in R1’s legs. Based on interviews conducted, LPA received inconsistent information regarding the condition of R1’s legs and feet. Interviews conducted indicated that on the morning of 04/29/2023, Staff Member 1 (S1) observed R1’s legs and feet to be warm, red, and swollen. S1 reported the observation to Staff Member 2 (S2). S2 observed R1’s legs to be warm, red, swollen and that R1 had an elevated temperature when they went to administer a pain medication for them. S2 notified Facility’s Health and Wellness Director of their observations and asked R1 if they would like 911 to be called. R1 refused. Interviews conducted indicated that in the afternoon of 04/29/2023, S1 observed that R1’s legs were worse than they were in the morning while S2 observed that R1’s legs were in the same condition as before. Review of Facility documentation and incident reports indicated that R1’ s Responsible Party was contacted and informed of R1’s condition on 04/29/2023. Continued on LIC9099C Continued from LIC9099C Review of Facility’s Clinical and Policy Procedure Manual states that “Facility staff are to notify the Health and Wellness Director or a Medication Technician when there is a resident change in status. A change in resident status can include the following: Elevated or subnormal temperature, wheezing, complaints of pain or discomfort, or change in skin integrity.” In addition, Review of R1’s Care Plan dated,05/22/2022, did not indicate a care need for R1 to have regular skin checks by the facility. This allegation is Unsubstantiated . There is an allegation that Staff did not respond to Resident’s Call cord. Report states that R1 pulled their call cord and no one came to assist them. Review of R1’s call light records for the months of March 2023 and April 2023 indicated that all calls were responded to within a time frame of 10 minutes or less. Staff interviews conducted stated that there haven’t been any concerns regarding the facility’s call light system and that it has been functioning appropriately. This allegation is Unsubstantiated. A finding that the Complaint Allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to Administrator. Signature on form confirms receipt of documents. Continued from LIC9099 A finding that the Complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC811 (Confidential Names), LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.