complaint·January 31, 2024

Interview with staff (S1) indicated that R1 is not really using their oxygen and only uses it if staff observe R1 is out of breath. Interview with staff (S3) indicated that R1 uses oxygen only when they walk around the facility, but most of the time they don't use it and don't need it. Interview with staff (S4) indicated that they were told that R1 didn't need their oxygen and R1 only uses their oxygen sporadically when they are walking. LPA reviewed R1's Physician's Report for RCFE (LIC 602A) dated 7/18/2023, which indicates that R1 has a diagnosis of Chronic Respiratory Failure and Hypoxia as of 5/2022. LPA reviewed Doctor's Order Sheet for R1's oxygen dated 10/20/2023, which states "PRN use of Oxygen when active or ambulating. Staff is to help patient with use of oxygen when needed." During visit conducted on 1/10/2024, LPA observed R1 in the activity room without their oxygen with them. LPA observed R1's oxygen in their apartment while R1 was in the activity room and not in their apartment. Based on interviews conducted, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. Exit interview was conducted with ED. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents. During visit conducted on 1/10/2024, LPA tested R1's call button in bathroom and observed staff respond to call in a timely manner. Interview with ED and multiple relevant parties indicated that R1 does not use and misplaces call button. Interview with ED indicated that R1 is no longer using a call button at the time of this report. No interviews conducted during investigation indicated any concerns regarding care and supervision for R1. Interviews with staff indicated that 2 hour rounds are completed for all residents in the Memory Care Unit of the facility to provide care and supervision to the residents in care. Interview conducted with R1 indicated that they had no concerns regarding the facility, they have everything they need, they are treated well by staff, they have plenty to do, and their care needs are being met in the timely manner. LPA observed an activities calendar for the Memory Care Unit of the facility and observed activities taking place throughout the facility during multiple visits. During multiple visits, LPA observed R1 participating in activities. Interviews with staff indicated that they have observed R1 actively participating in activities at the facility. Interview with staff and relevant party indicated that R1 has a hired companion every Monday, Wednesday, and Friday who ensures that R1 is participating in activities. Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted with ED. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.