Complaint·June 10, 2023

photos of R1 and R1's room, Housekeeping Room Checklist, Incident Report for R1, and a blank Controlled Drug Record. Regarding the allegation: Facility failed to provide a clean and sanitary environment, LPA Velazquez conducted interviews with residents and staff. 13 of 13 individuals interviewed provided conflicting statements and could not corroborate the allegation. LPA Velazquez reviewed photos of R1's room that revealed feces on the toilet seat in R1's bathroom and another picture with a soiled diaper and soiled toilet paper on the floor of R1's bathroom. 2 of 6 individuals interviewed stated that some staff will leave soiled diapers in resident rooms for housekeeping to throw out the following day. Regarding the allegation: Resident's call button is inoperable, 13 of 13 individuals interviewed provided conflicting statements and could not corroborate the allegation. At 11:45 AM during today's visit LPA Velazquez along with a Medication Technician (MT) toured the facility and tested several pull cords in resident rooms. Per the MT when a pull cord is activated it will light up on a large screen at the Health Services desk as well as staff cellphones or facility phones that the use the CISCOR application. When LPA and MT entered room 334 where there were 2 resident beds, they observed the pull cord system did not function properly which MT confirmed. A second MT came to test the pull cords in room 334 and also observed they were not functioning properly. One of the residents also did not have a pull cord at their bedside. Regarding the allegation: Facility is not following reporting requirements, LPA Velazquez reviewed and Incident Report for R1 for an incident dated November 8, 2022 that documented the submission date as November 22, 2022 which is late pursuant to regulation. The Incident Report also failed to document that R1's physician and R1's responsible party were notified of this incident. Executive Director Rhon Hipolito confirmed R1's physician and responsible party were not notified of R1's incident that occurred on November 8, 2022. Regarding the allegation: Facility does not answer phone calls, upon arrival at the facility today, LPA Velazquez observed signage documenting visiting hours from 8 AM - 8 PM at the main entrance of the facility which was locked. LPA Velazquez observed no staff present at the reception desk. At 8:30 AM LPA Velazquez proceeded to call the facility and left a voicemail message because no one answered the phone. Based on the observations of LPA Patricia Velazquez, interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Facility failed to provide a clean and sanitary environment, Resident's call button is inoperable, Facility is not following reporting requirements, and Facility does not answer phone calls are all deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is/are being cited on the attached LIC 9099D. An exit interview with Medication Technician Anthony Sanchez and a copy of this report along with the appeal rights, LIC 811, and LIC 9098 were provided at the time of this visit. photos of R1 and R1's room, Housekeeping Room Checklist, Incident Report for R1, and a blank Controlled Drug Record. Regarding the allegation: Facility failed to administer medication, LPA Velazquez reviewed R1's MAR for the months of January 2023 and February 2023. The facility also utilizes a Controlled Drug Record where medications such as PRN Morphine and Ativan are documented and signed by the staff assisting the resident with the self-administration of Morphine and Ativan. Per a Medication Technician, Morphine tablets are administered by facility staff with liquid Morphine administered by Hospice agency licensed health professionals only. The facility could not provide a copy of R1's Controlled Drug Record or their PRN Medication Administration Records. 13 of 13 individuals interviewed provided conflicting statements and could not corroborate the allegation. 2 of 6 individuals interviewed stated they administered controlled drugs Ativan and Morphine to R1 and documented it on the Controlled Drug Record with their signatures as required by the facility. Regarding the allegation: Facility failed to provide resident's record to emergency personnel, 13 of 13 individuals interviewed provided conflicting statements and could not corroborate the allegation. 2 of 6 individuals interviewed stated it is the facility's policy to immediately give emergency personnel resident documents such as the resident's Face Sheet and Medication List anytime a resident goes out to the hospital. Regarding the allegation: Facility failed to provide care and supervision to resident, 13 of 13 individuals interviewed provided conflicting statements and could not corroborate the allegation. 7 of 7 individuals interviewed indicated they felt the facility provided adequate care and supervision to residents in care. Based on the observations made by LPA Patricia Velazquez, interviews which were conducted and the records that were reviewed, 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 following allegations: Facility failed to administer medication, Facility failed to provide resident's record to emergency personnel, and Facility failed to provide care and supervision to resident are deemed UNSUBSTANTIATED. An exit interview was conducted with Medication Technician Anthony Sanchez and a copy of this report along with the appeal rights, LIC 811, and LIC 9098 were provided at the time of this visit.