complaint·February 28, 2024

It was also alleged that staff did not ensure R1’s records of centrally stored medication was complete . R1 returned to the facility upon discharge from the hospital the following day, February 23, 2023, at approximately 8:00 a.m., from being admitted for the treatment of a head injury after sustaining a fall at the facility. An interview conducted with OS1 revealed they arrived at the facility on February 23, 2023, at approximately 9:00 a.m., one hour after R1’s return, and requested Staff 1 (S1) to see R1’s Medical Administration Record (MAR), which is used to document dates and times staff administer medication to residents in care. The interview with OS1 also revealed looking through R1’s MAR and saw it was not complete and secured a photo. An outside source interview and facility record reviews confirmed R1’s MAR was not complete. Lastly, it was alleged that facility staff did not allow residents to have visitors during reasonable hours. An Outside Source 1 (OS1) Interview, LPA observation, and facility records reviews revealed the facility changed their visitation hours to 9:00 a.m. through 5:00 p.m. without any notice. An interview with OS1 revealed they had previously visited the facility outside the newly imposed visitation hours without any issue. OS1 also revealed coming to the facility at approximately 6:30 p.m. and was denied visitation. On March 2, 2023, the Department conducted an unannounced visit to the facility and observed a sign with visitation hours of 9:00 a.m. to 5:00 p.m. had been posted on the front door to the facility confirming the allegation. [See LIC 811 for Confidential Names] Based on evidence obtained, the allegations are substantiated because the preponderance of the evidence standard has been met. Deficiencies are being cited in accordance with the California Code of Regulations, Title 22, Division 6 Chapter 8, and listed on the 9099D. An exit interview was conducted with Caregiver Diaz who was notified a copy of this report along with the LIC 9099D and Licensee/Appeals Rights (LIC 9058 01/16) will be provided at the conclusion of the visit. Signature below confirms receipt of the documents. This is an amended version of the report dated 02/28/2024. An interview with Outside Source 1 (OS1) revealed R1 was in their wheelchair and reached for something causing them to fall out of their wheelchair. Based on facility staff and outside source interviews the allegation was determined to be unsubstantiated. A finding that the complaint 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. An exit interview was conducted with and a copy of this report along with Licensee/Appeal Rights (LIC 9058 01/16) will be provided to the Licensee. Licensee's signature below confirms receipt of the reports.