Complaint·October 10, 2023

On 4/13/2023 LPA interviewed witness regarding current facility allegations. According to witness R1 was in the bed upon each visit to R1. However, according to witness statements, witness visited R1 in the late and early hours of the night. According document review, on page 5 of 6 on LIC602A dated 8/23/2022 R1 is listed as non-ambulatory. According to staff interviews, facility record files and resident interviews, residents are not left in bed for an extended period of time. Therefore in regard to the allegation Staff leave resident in bed for an extended period of time, the allegation is Unsubstantiated. An unsubstantiated finding 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, therefore the allegation is UNSUBSTANTIATED. On 9/15/2023 LPA reviewed resident file documents for R1 received from facility on 4/18/2023. On 9/15/2023 LPA conducted staff and resident interviews regarding current allegations. On 10/10/2023 LPA conducted a tour of the facility and observed current residents to be clean. According to interviews with staff and residents there has been no residents that have been soiled for long periods of time. Based on interviews with staff, residents are checked every two hours to ensure they not soiled. On 9/15/2023 LPA received facility chart notes and files that have annotated times residents have been changed while soiled. Therefore in regard to the allegation Staff leave resident soiled for an extended period of time the allegation is unsubstantiated. An unsubstantiated finding 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, therefore the allegation is UNSUBSTANTIATED. On 9/15/2023 LPA reviewed resident files regarding services provided to R1. On page 3 of 6 of LIC602A letter E, Special Diet for R1 is filled and listed as "Puree Texture/CCHO Diet". On 9/15/2023 witness provided LPA with photographs of R1 meals and they are of puree texture. In accordance with R1s diet restrictions, facility did provide meal services to resident as prescribed. Therefore, the allegation Staff are not providing adequate meal services to resident is unsubstantiated. An unsubstantiated finding 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, therefore the allegation is UNSUBSTANTIATED. Cont on 9099-C On 9/15/2023 LPA reviewed resident files regarding services provided to R1. Based on facility files and chart files R1 received showering and bathing services at the minimum of 2 to 3 times a week as was in alignment with facility and hospice care services. Based on staff and resident interviews, residents received showering services based on facility agreements and services were logged in facility chart records. On 9/15/2023 LPA interviewed facility residents and staff regarding current allegations. Based on interviews and record review, R1 has been receiving showering by facility staff and hospice staff. Therefore the allegations Staff are not meeting resident’s showering needs is unsubstantiated. . An unsubstantiated finding 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, therefore the allegation is UNSUBSTANTIATED Exit interview held with Executive Director Morgan Greenwood and copy of report was provided. On 4/13/2023 LPA interviewed witness regarding current facility allegations. According to witness, R1 was not receiving pain medications as prescribed. On 9/15/2023 LPA conducted a review of facility medication logs and chart notes for the period of 9/23/2022 to 12/18/2022. Based on facility record review, facility did not provide medication to R1 as prescribed. Based on LPA observation, facility did not supply all requested documents as requested by LPA on 9/15/2023. On 9/18/2023 LPA received additional medication chart notes and documents and it was learned facility had not properly annotated medication resident had received. Therefore, staff did not annotate resident medication in accordance with Title 22 Regulations. Based on medication file review and review of the undated Sign-Out Medication Release Form received from the facility, records show missing pain medication that R1 did not receive upon out processing. Therefore in regard to the allegation Staff do not provide resident medication as needed, the allegation is Substantiated. Based on LPAs medication file review and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview with Administrator. Appeal rights and report given.