Complaint·January 29, 2025

Per R2 staff change his diaper as needed and reported that he has never been left in a soiled diaper. During the course of the interviews with staff, Staff 1 (S1) reported that staff usually do rounds every hour and stated that no other residents have complained about being left in a soiled diaper for a long period of time. Per S2 she changes R1’s diaper as needed and stated that she checks on R1 at least every two hours. Regarding the allegation that staff did not replace resident’s call button, the following was revealed: During the initial visit on November 07, 2024, and subsequent visit on January 29, 2025, LPA observed that R1’s call button was replaced. During the course of the interviews with Residents, R1 reported that their call button was broken the whole night of October 31, 2024, and stated that the call button was broken until the evening the next day. Per R2 his call button works good and stated that it gets answered within 10-20 minutes. Per R3 the call button works properly. During the course of the interviews with staff, S1 reported that the facility has extra call buttons and stated that it can replaced the same day. Regarding the allegation that staff did not serve resident meals, the following was revealed: During the investigation LPA reviewed documents including the Citrus Hills Assisted Living Service Plan dated October 08, 2024 for R1. Per Service Plan under Nutrition/Eating it states Resident will be offered choices in menu, with escorts and meal assistance as requested or needed. Per Service Plan it states provide meals three times daily, meal trays per resident request and verbal reminders for meals. During the course of the interviews with Residents, R2 reported that he gets three meals per day. Per R4 staff bring her three meals to her bedroom per day and stated that she always gets her breakfast, lunch and dinner. During the course of the interviews with staff, S2 reported that when a resident is sick, the kitchen staff bring the meals to the residents' bedroom. Regarding the allegation that facility staff did not give the resident's medication as prescribed, the following was revealed: LPA reviewed documents including the Physician Report (LIC602A) dated May 10, 2023, for R1. Per Physician Report R1 is not able to administer own prescription medications. During the investigation LPA reviewed documents including the Medication Administration Record (MAR) dated October 01, 2024, to November 07, 2024, and MAR dated January 01, 2025, to January 31, 2025. Per MAR dated October 01, 2024, to November 07, 2024, R1 was given their medication as prescribed except on October 24 and 25. CONTINUED ON LIC9099-C... Per MAR on October 24 and 25 the medications Mirtazapine Oral Tablet 15 MG and Quetiapine Fumarate Oral Tablet 200 MG were not administered. Per MAR on October 24 and 25 the chart code was entered as 7 which stands for other/see Nurse note. Per Nurse note on October 24 and 25 it states that the medication needs to be ordered. Per MAR dated January 01, 2025, to January 31, 2025, R1 was given their medications as prescribed. During the course of the interviews with Residents, R2 reported that staff administer his medications and reported that he gets his medications timely after every meal. During the course of the interviews with staff, S1 reported that residents get their medications as prescribed and stated that R1 is getting their medications as prescribed. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegations occurred as reported due to conflicting information. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed UNSUBSTANTIATED. For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations. LPA conducted an exit interview with facility representative, and a copy of this report was provided to the facility.