Complaint·December 3, 2024

Regarding the allegation, Resident was not treated with dignity and respect, the investigation revealed the following. W1 reported that R1 was put to bed without being fully dressed. W1 reported that R1 was put to bed with a top but no bottoms. R1 passed away in 2022 and could not be interviewed. LPA interviewed 2 staff members who worked at the facility at the time R1 resided at the facility. Both staff members reported that none of the residents were ever put to bed with only a top on. LPA interviewed the former Executive Director who reported they were unaware of any reports about residents being put to bed without clothing. Based on the evidence gathered the allegation is unsubstantiated, meaning although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violation did or did not occur. The investigation into the allegation, Resident's toileting needs were not being met, revealed the following. It was reported that R1 was not assisted with incontinence care. W1 reported that on that on August 22, 2020, when they visited R1 they were wearing 2 diapers and they were soiled. LPA interviewed 2 staff members who worked at the facility when R1 was residing at the facility. Both staff members reported that R1 was always assisted timely with incontinence care. Both staff members reported they did not recall any resident ever having 2 diapers put on them. The former Executive Director did not recall any issues with any of the residents having issues with incontinence care. Based on the evidence gathered the allegation is unsubstantiated meaning although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided. Regarding the allegation, staff did not notify responsible party of resident's change in condition, the investigation revealed the following. It was reported that R1 lost a tooth, and the facility did not inform R1’s responsible party. Photographic documentation was provided showing R1 is missing a tooth. Witness 1 (W1) reported visiting R1 on August 22, 2020, and they were missing a tooth. 2 staff members interviewed did not recall when or how R1 lost a tooth. LPA interviewed the former Executive Director (ED) who worked at the facility when the complaint was filed. ED reported they did not remember R1 and did not recall any resident losing a tooth. The preponderance of evidence standard has been met, therefore the allegation is substantiated. The investigation into the allegation, staff did not safeguard resident's personal belongings, revealed the following. It was reported that R1’s glasses were lost and never found. W1 reported that in September 2020 R1’s glasses were missing along with a picture collage. W1 reported that the Executive Director and staff were notified about the missing items. LPA interviewed 2 staff members and the former Executive Director (ED). Both staff members and the ED did not recall hearing any reports from R1 or their responsible party about any missing items. W1 reported that staff looked for both items but never found anything. W1 reported that they were contacted after R1’s roommate moved out by R1’s roommate’s family and the picture collage was found in R1’s roommate’s closet. W1 reported the picture collage was returned to them in 2022. A review of R1’s file revealed that R1’s file did not have a personal property inventory. LPA interviewed 2 staff members who did not recall R1 losing glasses. W1 does not recall if R1 had their items inventoried. W1 reported they were never provided with a report from the facility concerning the missing items. The facility could not provide any documentation concerning a theft and loss report for R1’s missing items. The former ED at the time the complaint was filed did not recall completing any documentation for R1’s missing items. The facility could not provide an inventory list for R1 or a signed document of R1’s refusal to have their items inventoried. According to CCR 87218(a)(1) the facility is required to complete a personal property inventory for residents. Based on the evidence gathered the preponderance of evidence standard has been met, therefore the allegation, staff did not safeguard resident’s personal belongings is substantiated. Deficiencies are being cited per Title 22 Division of the California Code of Regulations. An exit interview was conducted and a copy of the report was provided along with appeal rights.