Complaint·April 18, 2024

The medical professional also observed R1 was favoring the left side of their body due to a painful Stage II pressure injury located on their right heel. The Medical professional’s interview confirmed they contacted the facility regarding the pressure injury, but the facility stated they did not have knowledge. The facility provided basic services to R1 that included observations of R1. R1’s shower schedule for November 2020 reflected initials on the days R1 was provided showers. On 11/17/20, 11/20/20, 11/24/20, and 11/27/20 there were no initials to verify showers were provided or documentation to indicate R1 refused showers. The facility is required to meet the basic needs of the residents to include ensuring the residents are kept clean. Facility’s documentation of bathroom assistance reflected it was PRN, as needed. However, staff initials verified they assisted R1 with bathroom assistance for eight (8) of the thirty (30) days in November 2020, which indicated R1 required assistance. Staff interviews confirmed R1 was a full assist with toileting and diapers. Further staff interviews revealed finding R1 in soiled diapers on multiple occasions. Outside source interviews confirmed observing R1’s needs not being met due to being unkempt with dirty hair and black dirt on their feet. Based on interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation was found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Marie Hill whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1] R1’s medical record reflected they were prescribed a specific pain medication on 10/16/20, a PRN, as needed. A review of R1’s Medication Administration Records (MARs) for October 2020 indicated the medication was dispensed on 10/17/20 for moderate pain. MARs for November 2020 indicated the specific PRN medication was dispensed on 11/02/20 for moderate pain and 11/06/20 for severe pain. The facility was dispensing the medication as needed. Outside source interviews revealed a medical professional contacted the facility to inquire about the pain medication being dispensed. The medical professional reported the facility stated R1 was not complaining of pain, and it was unknown if staff were asking R1 if they were in pain. According to medication documentation, the licensee followed the physician’s order and provided as PRN, as needed. Staff interviews confirmed medications were dispensed as prescribed. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations are deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Marie Hill whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1]