complaint·April 22, 2025

The complaint alleges that Staff #1 (S1) bullies Resident #1 (R1) in an “angry way.” Reporting party indicated that after discussing the concerns about R1 to S1’s supervisor, S1 was not to provide care to R1 any longer, however S1 continued to enter R1’s room and demanded R1 shower. LPA reviewed R1’s care plan and physician’s report, both of which indicate R1 requires assistance with activities of daily living (ADLs) including assistance washing R1’s hair and body, assistance with dressing and grooming. R1’s care plan does indicate bathing on pm shift with a note indicating “7PM. Would like 3 showers weekly.” LPA Dulek interviewed staff related to the allegation. Staff indicated there is a shower schedule and the care staff provide showers per the schedule. S1 works the pm shift, so S1 would have been responsible for showering R1 at times. Staff interviewed stated that many care staff, including S1 talk to R1 regularly and share personal information with R1. At the time of the complaint and ongoing since, staff have continued to share information with R1 and have had personal disputes amongst the staff, which have been discussed with R1. Management is aware of the ongoing concern and have held meetings addressing professionalism in the workplace. Staff interviewed have heard from residents that staff have been rude towards the residents, including R1. 4 (four) of 6 (six) residents interviewed indicated that there have been staff in the past around the time of the complaint as well as current staff that have yelled and been intimidating towards the residents. Based on interview and record review, the preponderance of evidence standard has been, therefore the allegation is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency is cited (refer to LIC9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report was provided. The complaint alleges that R1 was given a pill, which R1 did not recognize and caused R1 to become tired and lowered R1’s heartrate. R1 questioned Staff #2 (S2) about the unrecognized medication, but S2 indicated the medications were all correct. LPA reviewed R1’s Medication Administration Record (MAR) and cross referenced R1’s physician’s ordered medication list. LPA confirmed that all medications listed on the MAR have been ordered by R1’s physician. R1’s physician’s report does indicate R1 was able to store and administer their own prescription and PRN medications, however R1’s care plan indicates R1 was on medication management at that time. R1 and their family member stated R1 was taken to the hospital as a result of low heart rate. LPA reviewed incident reports for the time frame referenced in the complaint, but no incident reports were submitted relating to R1 being hospitalized, nor were there any care notes entered or other documentation to reflect outside care was needed. Interview with S2 revealed that R1 did not ask about their medications during the time of the alleged error and all medications were administered to R1 as prescribed. All other residents interviewed indicated their medications are administered on time and as prescribed. LPA confirmed R1 is no longer on medication management with the facility and is instead storing their own medications at this time. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time. No citations issued related to the above allegation. Exit interview conducted. A copy of today’s report was provided.