complaint·March 25, 2024

LPA reviewed R1’s July 2020 Medication Administration Record along with R1’s medication list which revealed no documented resident refusals of medications or missed doses. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was reviewed and provided along with Confidential Names List (LIC811). One (1) of six (6) interviews conducted reported that R1 had been found on 7/24/2020, around 12:00 p.m., with injuries to their head and was subsequently sent to the hospital. One (1) of six (6) interviews conducted reported R1 was found in their bed, soaked in urine, with a bruise to their eye, which was swollen to the size of a golf ball. Staff interviews revealed no falls had been reported prior to the discovery of the residen t . Records reviewed failed to show a record of any fall prior the incident on 7/24/2020. Medical records were requested and obtained; an American Medical Response (AMR) report revealed emergency personnel arrived to the facility at 11:52 A.M., and observed R1 with a, "large hematoma over left eye with ecchymosis left eyelid". The Discharge/Transfer Documentation report revealed R1 was admitted to Pomona Valley Hospital on July 24, 2020, and diagnosed with Blunt Head Trauma and Traumatic Orbital Hematoma. Regarding the allegation of, “Staff did not provide adequate food service”, LPA reviewed R1’s Needs and Services Plan dated 2/22/2019, which noted R1 required meal reminders. One (1) of six (6) interviews conducted revealed R1 was able to eat on their own if facility staff provided R1 with a meal in R1’s bedroom. One (1) of six (6) interviews conducted revealed facility staff frequently required reminders to provide R1 with a meal and witnessing facility staff rushing to put meals together to provide for R1 because they had forgotten to distribute R1’s meals. Based on LPA’s interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations (Title 22, Division 12, Chapter 1), are cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was provided along with Confidential Names List (LIC811) and Appeal Rights.