complaint·August 23, 2022

Therefore, based on record review, the allegation “Staff did not prevent resident from wandering away from the facility” is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met. Due to observations made by LPA Colvin, the facility was cited and deficiencies noted on LIC 9099 D. An exit interview was conducted where this report and appeal rights were discussed. A copy this report, LIC 9099D, and appeal rights were provided to Memory Care Director Bobbie Rodgriguez during the exit interview. Therefore, based on record review and interviews conducted, the allegation “Staff did not prevent resident from engaging in inappropriate behaviors” is UNSUBSTANTIATED. Regarding allegation “Staff refused to provide resident representative with medical records”: LPA Colvin interviewed relevant witnesses regarding R1’s Power of Attorney’s (POA) request for all of R1’s records from the facility. Interviews conducted by LPA Colvin reveal conflicting dates on when the records were requested, ranging from the day prior to R1 moving out of the facility to a week prior to R1 moving out of the facility. In LPA Colvin’s interview with Administrator Patrick Mackadoo-Morton, the Administrator stated that the reason the records could not be provided the same day the POA requested was due several factors, such as: the Administrator not being present, it being after business hours on a Friday, and that the POA was requesting records which may have other residents listed in them as well (such as internal incident reports), which the Administrator would have to redact for other resident’s privacy. Title 22 Regulations section 87468.2(a)(19) requires that facilities to produce resident records for the resident or representatives within two business days. Since LPA Colvin is unable to confirm which date R1’s POA requested the records, and one of the dates provided via interview falls within the allotted two business days, the allegation “Staff refused to provide resident representative with medical records” is UNSUBSTANTIATED. Regarding allegation “Staff are not following resident's physician orders”: LPA Colvin conducted interviews and reviewed relevant documents from R1’s facility file regarding medications prescribed to R1 as well as dates administered, and dates refused. LPA Colvin confirmed through interviews that R1 requested information on R1’s medications, such as side effects, and after staff provided this information to R1, R1 refused to take some of their medication. Facility staff communicated with R1’s POA and R1’s physician regarding R1’s concerns about the medication and subsequent refusals. Facility staff continued to offer R1 all prescribed medications at directed administration intervals, but R1 continued to refuse certain medications. Residents retain the right to refuse medications and staff are not permitted per Title 22 Regulations to force medications or camouflage them in any substance. Therefore, due to record review and interviews conducted, the allegation “Staff are not following resident's physician orders” is UNSUBSTANTIATED. Regarding allegation “Facility did not notify resident's authorized representative of incidents”: LPA Colvin reviewed pertinent documents from R1’s facility file as well as interviewed facility staff regarding specific incidents of concern with R1 and how information was communicated to R1’s POA. LPA Colvin confirmed that regarding R1’s pulling out of their hair that while staff had previously seen some hair in R1’s trash can on 8/4/22, there was not a concern regarding R1 pulling out their hair until 8/12/22. . Staff interviews are consistent in that this was not observed until the evening (approximately 7:30pm) on 8/12/22, and at that time R1 was being visited by their POA, so the information was relayed to POA in person verbally. Notes in R1’s file support these statements, and interviews reflect that R1 did not have prior behavior of pulling out their hair. Other reportable incidents observed by LPA Colvin in R1’s file include R1’s medication refusal and an elopement from the facility on 4/4/22. Both items were also reported to R1’s POA, which is supported by documentation and interviews. Therefore, based on interview and record review, the allegation “Facility did not notify resident's authorized representative of incidents” is UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted with Memory Care Director Bobbie Rodgriguez and a copy of this report was provided. Regarding allegation “Facility denied resident from having visitors”: LPA Colvin conducted interviews with persons related to the allegation and all parties agree that R1 was never denied from having visitors, though after an incident between the Administrator and R1’s POA, the Administrator did state that they would institute modifications to R1’s POA visiting them, due to the Administrator’s concern for R1’s safety. Since R1 was never denied any visitors and R1 was moved from the facility prior to this new modification being implemented in any future visitation, the allegation “Facility denied resident from having visitors” is UNFOUNDED Regarding allegation “Resident is not allowed to participate in activities”: LPA Colvin interviewed persons related to the allegation as well as reviewed staff notes for R1’s facility file. LPA Colvin observed a staff note in which it was documented that R1’s POA was requesting for R1 to attend some events in the Assisted Living portion of the facility. The note reflects that staff informed the POA that R1 was welcome to attend the events, but that the POA would need to accompany R1. R1 was a resident in the Memory Care unit of the facility, which is locked, and therefore it is practical that R1 would need supervision to be in the Assisted Living portion of the facility, which is not locked. Additional interviews suggest that R1 was not prohibited from attending other activities, which are offered to Memory Care residents. Therefore, based on interviews conducted and record reviewed, the allegation “Resident is not allowed to participate in activities” is UNFOUNDED. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. An exit interview was conducted with Memory Care Director Bobbie Rodgriguez and report provided.