Complaint·September 11, 2023

LPA reviewed facility document on R1 named "ADL Care Details" dated 6/27/23, with the following information: Eating/Diet: Resident able to consume meals independently, aspiration precautions, Nectar thick liquids, Mechanical chopped texture. Offer fluids, ensure resident is to be sitting upright to prevent aspiration. Medications: Medication assistance with Med-Aide on duty, resident to sit-fully upright, takes meds whole in applesauce and nectar thick liquids. The LPA reviewed obtained photos showing R1 being fed food by staff, on two separate occasions, while in a halfway lying position in their bed. LPA observed in the photos, staff did not have the resident sitting upright when providing food, to help prevent resident from aspirating. Per review of resident records, All food and liquids are to be provided to the resident (R1) while in an upright sitting position. Resident incidents did occur where the resident went out 911 due to choking on food, and/or aspirating. Per investigation, facility staff were aware of R1's specific Dr's Orders regarding medications and food/drinks. Administrator Alsup, Chancellor Consultant Regional staff, stated that they came into the facility, July 2023, in regards to the concerns with R1's medication assistance by staff, and food & liquids being provided by staff, concerns that Dr's Orders were not being followed by staff. Administrator Alsup, and facility LVN Nunn, reviewed incidents, and held in-service training(s) with all staff, including caregivers, med-technicians, and kitchen staff, regarding R1's care plan and Dr's Orders. Based on LPA interviews, review of records, photos and information obtained, the investigation has revealed that the allegations of " Medications are not being provided as ordered" and "Special diet, including liquids, are not being provided as ordered" are substantiated. Due to the substantiation of the allegation(s), a citation, 87465(a)(4) Incidental Medical & Dental Care- The licensee shall assist residents with self-administered medications as needed, will be cited today, see LIC9099D. The preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited. Failure to correct deficiencies by due dates, may result in additional deficiency citations and/or civil penalties being assessed. Appeal Rights Given. Exit interview conducted with the Administrator Kim Alsup