complaint·October 25, 2023

Regarding the allegation Staff did not prevent a resident from causing harm to other residents. Incident Report dated 03/13/2023 documents Resident 1 assaulted two other facility residents. LPA Hurt reviewed several text and email exchanges between facility Administrator and Resident 1’s Responsible Party documenting incidents of Resident 1 hitting other facility residents. Based on records reviewed the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED at this time. Regarding the allegation Staff did not properly report incidents involving a resident. LPA Hurt reviewed medical records documenting Resident 1 was taken to the hospital on 02/06/2023, this incident was not reported to State Licensing. LPA Hurt observed text messages dated March 4, 2023 documenting Resident 1 assaulted another facility resident. This incident was not reported to State Licensing. This incident from March 4, 2023 was not reported to State Licensing. Based on records reviewed during this investigation the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED at this time. Regarding the allegation Staff are not providing adequate care and supervision to a resident. LPA Hurt reviewed Incident Report dated 03/13/2023 documents Resident 1 assaulted two other facility residents. Staff 1 stated at times working alone with 4 residents providing all care and supervision, meals, and incontinent needs made it difficult to provide supervision. Based on records reviewed during this investigation the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED at this time. Regarding the allegation Staff mishandled a resident's medication while in care. LPA reviewed Centrally Stored Medication log for Resident 1 documenting a medication with a start date of 01/01/2023 with no quantity, date filled, expiration date, or Pharmacy name. The medication is not documented on any Medication Administration Record. It is unclear if this medication was given to Resident 1 at the facility. Based on LPA observation, and records reviewed during this investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED at this time. Regarding the allegation Staff is not following the admission agreement. Admission agreement documents under section “Notice of Rate Changes." If the facility rate for basic services changes because the resident’s needed/desired services changes as determined by an appraisal (see resident appraisals / evaluation of your needs), the rate change will occur when the change in service occurs, as long as at least thirty days have passed since the signing of the admission agreement. We shall provide the resident or the representative a written itemized notice of a rate increase after the change in services which will include a detailed itemized explanation of the additional services to be provided. Responsible Party for Resident 1 was not given a detailed itemized explanation of the additional services provided. The invoice provided is not dated. Based on Records reviewed during this investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED at this time. The following Deficiencies are being Cited Per Title 22 Regulations. Exit interview conducted with Licensee Jessica Johnson, and a copy of this report provided. Continued.. Regarding the allegation Resident sustained multiple injuries while in care. Resident 1 did have documented bruising during a visit to his Physician on 02/13/2023. Resident 1 also had documented un-witnessed falls. Facility staff documented Resident 1 was refusing to use his wheelchair, and walker. Based on the interviews conducted, documentation obtained and reviewed, and the information received during this investigation, the preponderance of evidence standard has not been met; therefore, the above allegation is found to be unsubstantiated at this time. Regarding the allegation Staff disclosed confidential information. Licensee did text Responsible Party for Resident 1 asking if their contact information can be given to the Responsible Parties of other residents. Resident 1’s Responsible party was not contacted by any other residents Responsible Parties. Based on the interviews conducted, documentation obtained and reviewed, and the information received during this investigation, the preponderance of evidence standard has not been met; therefore, the above allegation is found to be unsubstantiated at this time. Regarding the allegation Staff are falsifying a resident's medical records. Facility staff documented Resident 1’s medication given three times daily once at 4 p.m. despite Resident 1 leaving for the hospital at approximately 3 p.m. Facility staff did give Resident 1 his medication as listed on the prescription despite it not being the exact time. Based on the interviews conducted, documentation obtained and reviewed, and the information received during this investigation, the preponderance of evidence standard has not been met; therefore, the above allegation is found to be unsubstantiated at this time. Regarding the allegation Staff did not provide an authorized representative access to resident records. LPA reviewed text messages between Resident 1's Responsible Party, and Licensee Jessica Johnson discussing Resident 1's records. Based on these messages it is unclear when the documents were originally requested, and who requested the records. A written request was not given to Licensee requesting Resident 1's records. Based on the interviews conducted, documentation obtained and reviewed, and the information received during this investigation, the preponderance of evidence standard has not been met; therefore, the above allegation is found to be unsubstantiated at this time. No Deficiencies Cited Per Title 22 Regulations. Exit interview conducted with Licensee Jessica Johnson, and a copy of this report provided.